Consensus guidelines for the management of intraductal papillary mucinous neoplasms of the pancreas

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This week’s discussion included information about the utility of the Fukuoka criteria.

Srinivasan N, et al. Systematic review of the clinical utility and validity of the Sendai and Fukuoka Consensus Guidelines for the management of intraductal papillary mucinous neoplasms of the pancreas.HPB (Oxford). 2018 Jun;20(6):497-504.

Free full-text. 

RESULTS: Ten studies evaluating the FCG, 8 evaluating the SCG and 4 evaluating both guidelines were included. In 14 studies evaluating the FCG, out of a total of 2498 neoplasms, 849 were malignant and 1649 were benign neoplasms. Pooled analysis showed that 751 of 1801 (42%) FCG+ve neoplasms were malignant and 599 neoplasms of 697 (86%) FCG-ve neoplasms were benign. PPV of the high risk and worrisome risk groups were 465/986 (47%) and 239/520 (46%) respectively. In 12 studies evaluating the SCG, 1234 neoplasms were analyzed of which 388 (31%) were malignant and 846 (69%) were benign. Pooled analysis demonstrated that 265 of 802 (33%) SCG+ve neoplasms were malignant and 238 of 266 SCG-ve (90%) neoplasms were benign.

CONCLUSION: The FCG had a higher positive predictive value (PPV) compared to the SCG. However, the negative predictive value (NPV) of the FCG was slightly lower than that of the SCG. Malignant and even invasive IPMN may be missed according to both guidelines.

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Pathogenesis of diversion colitis

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This week’s discussions included the causes of diversion colitis.

Tominaga K, et al. Diversion colitis and pouchitis: A mini-review. World J Gastroenterol. 2018 Apr 28;24(16):1734-1747.

Free full-text.

“The basic mechanisms underlying diversion colitis are still unclear. Glotzer hypothesized that it might be the result of bacterial overgrowth, the presence of harmful bacteria, nutritional deficiencies, toxins, or disturbance in the symbiotic relationship between luminal bacteria and the mucosal layer[2]. Reportedly, concentrations of carbohydrate-fermenting anaerobic bacteria and pathogenic bacteria are reduced in de-functioned colons[5,23,53] and these reports indicate that the overgrowth of anaerobic bacteria or a pathogenic bacterium is unlikely to be an important etiological factor. On the other hand, there is an increase of nitrate-reducing bacteria in patients with diversion colitis[7] and nitrate-reducing bacteria produce nitric oxide (NO) which plays a protective role in low concentrations, but at higher levels it becomes toxic to the colonic tissue[54]. Thus, it has been suggested that increases in nitrate-reducing bacteria may result in toxic levels of NO, leading to the diversion colitis.” (Tominaga, 2018, p. 1739)

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Perioperative Management of Biologic and Immunosuppressive Medications in Patients With Crohn’s Disease

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Lightner AL. Perioperative Management of Biologic and Immunosuppressive
Medications in Patients With Crohn’s Disease. Dis Colon Rectum. 2018 Apr;61(4): 428-431.

EVALUATION AND TREATMENT ALGORITHMS

Algorithm 1

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CME & Education: VTE Prevention in the Hospital: New Approaches and Expert Perspectives

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This continuing education offering is part of Medscape‘s series, Contemporary Topics in Antithrombotic Therapy. (You’ll need a Medscape account to view and/or accrue CME credit.)

Authors: Gary E. Raskob, PhD; Steven B. Deitelzweig, MD; Alex C. Spyropoulos, MD

CME Released: 12/22/2019; Valid for credit through: 12/22/2020

“…[W]e are going to talk about VTE, its importance in the hospital population of patients admitted with medical illness, and how we can work to reduce the burden of disease from this important condition.

About half of all hospitalizations in the United States are for medical illnesses, such as heart failure, pneumonia, stroke, and so on. Of these patients, about half of them are at risk for VTE and about 25% are at high risk for VTE.

Those who develop VTE tend to have pretty severe consequences, and these consequences persist beyond hospitalization.”

Bariatric Surgery vs. Medical Therapy for Diabetes and Obesity

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Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes–5-Year Outcomes.N Engl J Med. 2017;376(7):641–651.

Full-text for Emory users.

“At 5 years, the criterion for the primary end point was met by 2 of 38 patients
(5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons).”

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Open Mesh Vs. Lap Mesh Repair of Inguinal Hernia

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Bullen NL, Massey LH, Antoniou SA, Smart NJ, Fortelny RH. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis. Hernia. 2019; 23(3):461–472.

Full-text for Emory users.

RESULTS: This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

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Article of interest: Long-term Results of a RCT of a Nonoperative Strategy (Watchful Waiting) for Men With Minimally Symptomatic Inguinal Hernias

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This week’s discussion included what are the best treatment options for asymptomatic and symptomatic inguinal hernias.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515.

Results: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.

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