e361

Diseases of the Colon & Rectum Volume 57: 6 (2014)

least 5 mm in our study) around the ­residual tumor/scar and a full-thickness excision including the perirectal fat. Last, Bujko and Szczepkowski raise a question related to the absence of mucosal abnormalities. This is a good question because, in the absence of mucosal abnormality, the surgeon is not able to localize the area to be excised. All of our patients presented with mucosal abnormalities; however, it is useful to tattoo the residual tumor/scar early after the completion of pCRT. REFERENCES 1. Pucciarelli S, De Paoli A, Guerrieri M, et al. Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum. 2013;56:1349–1356. 2. Callender GG, Das P, Rodriguez-Bigas MA, et al. Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer. Ann Surg Oncol. 2010;17:441–447. 3. Bujko K, Richter P, Smith FM, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical ­re-operation for poor responders: a prospective multicentre study. Radiother Oncol. 2013;106:198–205. 4. Garcia-Aguilar J, Shi Q, Thomas CR Jr, et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19:384–391. 5. Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg. 2012;99:1211–1218.

Salvatore Pucciarelli, M.D. Padova, Italy Vincenzo Valentini, M.D. Rome, Italy Antonino De Paoli, M.D. Aviano, Italy Isacco Maretto, M.D. Padova, Italy Dis Colon Rectum 2014; 57: e361 DOI: 10.1097/DCR.0000000000000132 © The ASCRS 2014

Should Gum Chewing Be Included in Enhanced Recovery After Surgery Programs for Colorectal Surgery? To the Editor–We have read with great interest the recent article by Ho et al,1 who performed a meta-analysis on the effect of gum chewing after colorectal surgery. The authors have performed a substantial and extensive literature search and

included several recent randomized controlled trials.2–4 However, there are some serious concerns regarding the methodology used and the conclusions drawn by the authors in this meta-analysis. First, the authors analyzed continuous variables statistically using the standard mean difference. However, to our knowledge, the weighted mean difference should be used for continuous variables expressed in the same units,5 which is consistent with other published meta-analyses on this topic.6–9 Second, they assessed the included studies using the Cochrane Collaboration’s risk of bias tool. Unfortunately, they have not used it in a proper way. For example, in their results, all of the included trials used blinding, which conflicts with our finding and other published meta-analyses.6–9 In addition, the quality checklist that they used was not consistent with that of the Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0. Methodologic assessment of included studies plays a critical role in a m ­ eta-analysis, because the meta-analysis depends on the quality of included studies for their results.10 Third, results from this meta-analysis need to be evaluated with caution. The authors concluded that sham feeding confers no advantage if patients are placed on a rapid postoperative feeding regimen. This is a major finding. However, do the authors really want to base their clear-cut recommendation on 2 randomized controlled trials including 271 randomized patients? REFERENCES 1. Ho YM, Smith SR, Pockney P, Lim P, Attia J. A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery protocols? Dis Colon Rectum. 2014;57:115–126. 2. Bahena-Aponte JA, Cárdenas-Lailson E, Chávez-Tapia N, Flores-Gama F. Usefulness of chewing gum for the resolution of postoperative ileus in left colon resections [in Spanish]. Rev Gastroenterol Mex. 2010;75:369–373. 3. Lim P, Morris OJ, Nolan G, Moore S, Draganic B, Smith SR. Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial. Ann Surg. 2013;257: 1016–1024. 4. Zaghiyan K, Felder S, Ovsepyan G, et al. A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding. Dis Colon Rectum. 2013;56:328–335. 5. Moher D, Jadad AR, Klassen TP. Guides for reading and interpreting systematic reviews: III. How did the authors synthesize the data and make their conclusions? Arch Pediatr Adolesc Med. 1998;152:915–920. 6. Chan MK, Law WL. Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review. Dis Colon Rectum. 2007;50:2149–2157. 7. Parnaby CN, MacDonald AJ, Jenkins JT. Sham feed or sham? A meta-analysis of randomized clinical trials assessing the effect of gum chewing on gut function after elective colorectal surgery. Int J Colorectal Dis. 2009;24:585–592. 8. Purkayastha S, Tilney HS, Darzi AW, Tekkis PP. ­Meta-analysis of randomized studies evaluating chewing gum to enhance

e362

LEtters to the Editor

postoperative recovery following colectomy. Arch Surg. 2008;143:788–793. 9. Vásquez W, Hernández AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg. 2009;13:649–656. 10. Barie PS. Does a well-done analysis of poor-quality data constitute evidence of benefit? Ann Surg. 2012;255:1030–1031.

Cheng-Le Zhuang, M.D. Wei-Zhe Chen, M.D. Zhen Yu, M.D., Ph.D. Wenzhou, Zhejiang Province, China Dis Colon Rectum 2014; 57: e362 DOI: 10.1097/DCR.0000000000000126 © The ASCRS 2014

The Author Replies To the Editor—We thank Dr Yu and colleagues for their interest in the above meta-analysis. We agree wholeheartedly that methodologic assessment of included studies in any meta-analysis plays a critical role. To that extent we were careful to point out the flaw of possible publication bias associated with the reduction in complication rates, as well as the heterogeneity of postoperative feeding regimes used in the analyzed trials. In addition, we commented on limited reporting of postoperative morbidity by the selected trials. With respect to the appropriate use of statistics, Dr Yu and colleagues can rest assured that the standardized mean difference is indeed weighted by the inverse variance when it is pooled, with the standardization implying that if different studies used different scales then this is adjusted for. Our pooling method does indeed weight each study estimate. With respect to the Cochrane Handbook for Systematic Reviews of Interventions1 risk of bias tool, with a predefined 6-section checklist, we feel that it has been used in the manner described by the handbook. It will always be a selective tool, slightly open to interpretation, but it is important to note that lack of blinding does not imply a high risk of bias related to blinding. This is quite clearly

outlined in the handbook, and it appears Dr Yu and colleagues have failed to grasp this: “…all the included trials used blinding.”2 In many surgical trials, blinding is quite clearly impossible, and the assessors role is to determine whether a lack of blinding could potentially result in a high or low risk of bias rather than merely state whether blinding was used. The consistent reporting of the rather objective outcomes of time to flatus and passage of feces was one of the most striking elements of this meta-analysis. All 10 of the studies reported on both of these outcomes. In view of this, we felt comfortable making rather clear-cut recommendations. In our opinion, the combination of a nonclinically relevant outcome for all 612 patients (30-31 minutes of improvement in the return of gastrointestinal function), in association with no statistical improvement in the rapid feeding group (n = 271), meant that we were satisfied to make a clear-cut recommendation for the group of patients having rapid postoperative feeding. We would encourage Dr Yu and colleagues to conduct a larger-scale randomized clinical trial to further examine sham feeding in this group of patients if they feel that more information is required. REFERENCES 1. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at: http://www. cochrane.org/handbook. 2. Ho YM, Smith SR, Pockney P, Lim P, Attia J. A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery protocols? Dis Colon Rectum. 2014;57:115–126.

Stephen Ridley Smith, M.B.B.S., B.Sc., F.R.A.C.S., M.S. Newcastle, New South Wales, Australia Dis Colon Rectum 2014; 57: e362 DOI: 10.1097/DCR.0000000000000120 © The ASCRS 2014

Should gum chewing be included in enhanced recovery after surgery programs for colorectal surgery?

Should gum chewing be included in enhanced recovery after surgery programs for colorectal surgery? - PDF Download Free
177KB Sizes 2 Downloads 3 Views