Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: time to change traditional practice.

BACKGROUND: To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis. METHODS: A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters. RESULTS: The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61). CONCLUSION: Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.

Minimally invasive surgery for Inflammatory Bowel Disease: a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques.

BACKGROUND: To evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease (IBD). METHODS: Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. Primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias. RESULTS: Eleven non-randomised studies (n=5,566 patients) divided between those undergoing robotic (n=365) and conventional laparoscopic (n=5,201) surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery (P=0.03).Laparoscopic surgery was associated with a significantly shorter operative time (P=0.00001). No difference was found in conversion rates to open surgery (P=0.15), anastomotic leaks (P=0.84), abscess formation (P=0.21), paralytic ileus (P=0.06), surgical site infections (P=0.78), re-operation (P=0.26), re-admission rate (P=0.48), and 30-day mortality (P=1.00) between the groups.Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy (P=0.03). CONCLUSION: Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with specific focus on important IBD-related metrics.

Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis.

BACKGROUND: Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. METHODS: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS: 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). CONCLUSION: There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.

Comparison of the Colonic J-Pouch Versus Side-To-End Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated. RESULTS: Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, P = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: -8.76; 95% CI - 15.91 - 1.61, P = .02]. DISCUSSION: Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.

Faecal Microbiota Transplantation [FMT] in the Treatment of Chronic Refractory Pouchitis: A Systematic Review and Meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis is to assess the efficacy and safety of faecal microbiota transplantation [FMT] in the treatment of chronic pouchitis. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted using the following databases and clinical trial registers: Medline, Embase, Scopus, Cochrane Database of Systematic Reviews [CENTRAL], clinical trials.gov, ScienceDirect, and VHL [virtual health library]. The primary outcome was clinical response/remission in patients treated with FMT. Secondary outcomes included safety profile, quality of life, and changes in the gut microbiome. RESULTS: Seven observational cohort studies/case series and two randomised, controlled trials with a total of 103 patients were included. The route, preparation, and quantity of FMT administered varied among the included studies. Clinical response rate of 42.6% with a remission rate of 29.8% was estimated in our cohort following FMT therapy. Minor, self-limiting, adverse events were reported, and the treatment was well tolerated with good short- and long-term safety profiles. Successful FMT engraftment in recipients varied and, on average, microbial richness and diversity was lower in patients with pouchitis. In some instances, shifts with specific changes towards abundance of species, suggestive of a 'healthier' pouch microbiota, were observed following treatment with FMT. CONCLUSION: The evidence for FMT in the treatment of chronic pouchitis is sparse, which limits any recommendations being made for its use in clinical practice. Current evidence from low-quality studies suggests a variable clinical response and remission rate, but the treatment is well tolerated, with a good safety profile. This review emphasises the need for rationally designed, well-powered, randomised, placebo-controlled trials to understand the efficacy of FMT for the treatment of pouchitis.

Does Omentopexy Make a Difference in Laparoscopic Sleeve Gastrectomy for Obesity Treatment? A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis.

BACKGROUND: Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse. METHODS: A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis. RESULTS: Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches. CONCLUSIONS: A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

Single-incision versus multi-port laparoscopic ileocolic resections for Crohn's disease: Systematic review and meta-analysis.

Introduction: The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD). Patients and Methods: A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis. Results: Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable. Conclusion: SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.

Comparison of Midline and Off-midline specimen extraction following laparoscopic left-sided colorectal resections: A systematic review and meta-analysis.

Aims: This study aims to evaluate comparative outcomes following midline versus off-midline specimen extractions following laparoscopic left-sided colorectal resections. Methods: A systematic search of electronic information sources was conducted. Studies comparing 'midline' versus 'off midline' specimen extraction following laparoscopic left-sided colorectal resections performed for malignancies were included. The rate of incisional hernia formation, surgical site infection (SSI), total operative time and blood loss, anastomotic leak (AL) and length of hospital stay (LOS) was the evaluated outcome parameters. Results: Five comparative observational studies reporting a total of 1187 patients comparing midline (n = 701) and off-midline (n = 486) approaches for specimen extraction were identified. Specimen extraction performed through an off-midline incision was not associated with a significantly reduced rate of SSI (odds ratio [OR]: 0.71; P = 0.68), the occurrence of AL (OR: 0.76; P = 0.66) and future development of incisional hernias (OR: 0.65; P = 0.64) compared to the conventional midline approach. No statistically significant difference was observed in total operative time (mean difference [MD]: 0.13; P = 0.99), intraoperative blood loss (MD: 2.31; P = 0.91) and LOS (MD: 0.78; P = 0.18) between the two groups. Conclusions: Off-midline specimen extraction following minimally invasive left-sided colorectal cancer surgery is associated with similar rates of SSI and incisional hernia formation compared to the vertical midline incision. Furthermore, there were no statistically significant differences observed between the two groups for evaluated outcomes such as total operative time, intra-operative blood loss, AL rate and LOS. As such, we did not find any advantage of one approach over the other. Future high-quality well-designed trials are required to make robust conclusions.

Outcomes following open versus laparoscopic multi-visceral resection for locally advanced colorectal cancer: A systematic review and meta-analysis.

BACKGROUND: This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery. MATERIALS AND METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis. RESULTS: Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups. CONCLUSION: Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis.

AIMS: To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch. METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis. RESULTS: Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81). CONCLUSION: Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

Meta-analysis of the demographic and prognostic significance of gastrointestinal symptoms in COVID-19 patients.

Background and Aim: To evaluate the demographic and prognostic significance of gastrointestinal (GI) symptoms in patients with coronavirus disease 2019 (COVID-19). Methods: A systematic search of electronic information sources was conducted. Combined overall effect sizes were calculated using random-effects models for baseline demographic factors and outcomes including mortality, intensive care unit (ICU) admission, and length of hospital stay. Results: Twenty-four comparative observational studies reporting a total of 51 522 COVID-19 patients with (n = 6544) or without (n = 44 978) GI symptoms were identified. The patients with GI symptoms were of comparable age (mean difference [MD]: 0.25, 95% confidence interval [CI] -2.42 to 2.92, P = 0.86), rate of pre-existing hypertension (odds ratio [OR]: 1.11, 95% CI 0.86-1.42, P = 0.42), diabetes mellitus (OR: 1.14, 95% CI 0.91-1.44, P = 0.26), and coronary artery disease (OR: 1.00, 95% CI 0.86-1.16, P = 0.98) compared with those without GI symptoms. However, there were significantly more male patients in the GI symptoms group (OR: 0.85, 95% CI 0.75-0.95, P = 0.005). The presence of GI symptoms was associated with similar risk of mortality (OR: 0.73; 95% CI 0.47-1.13, P = 0.16), ICU admission (OR: 1.15; 95% CI 0.67-1.96, P = 0.62), and length of hospital stay (MD: 0.43; 95% CI -0.73 to 1.60, P = 0.47) when compared with their absence. Conclusion: Meta-analysis of the best possible available evidence demonstrated that GI symptoms in COVID-19 patients do not seem to affect patients with any specific demographic patterns and may not have any important prognostic significance. Although no randomized studies can be conducted on this topic, future high-quality studies can provide stronger evidence to further understand the impact of GI symptoms on outcomes of COVID-19 patients.

A Spontaneous Groin Collection Masquerading as an Irreducible Inguinoscrotal Hernia.

This case report details a clinically rare presentation in which a middle-aged man was diagnosed clinically with a large irreducible inguinoscrotal hernia. However, intraoperatively, a large volume of old blood/clots was seen and aspirated, without a definite hernia being identified. Inguinal hernias remain a clinical diagnosis, and imaging is used only in equivocal cases. Owing to the number of differential diagnoses associated with groin swelling, careful clinical assessment is critical in differentiating between the various causes. Rupture of the inferior epigastric vessels was suspected, and although rare, it should be considered as a differential diagnosis as this may alter ongoing management.

Comparison of surgical and oncological outcomes between oncoplastic breast-conserving surgery versus conventional breast-conserving surgery for treatment of breast cancer: A systematic review and meta-analysis of 31 studies.

AIMS: To evaluate comparative outcomes of oncoplastic breast conserving surgery (OBCS) versus conventional breast conserving surgery (BCS) for breast cancer treatment. METHODS: A systematic search of multiple electronic data sources was conducted, and all eligible studies comparing OBCS and BCS were included. Characteristics of the tumour includes preoperative size of tumour on imaging and the weight of the specimen after resection. While positive margins rate, re-excision rate, completion mastectomy rate and loco-regional recurrence were considered as oncological outcome parameters. Post-operative complications include surgical site infection (SSI), seroma, haematoma and skin/nipple necrosis. RESULTS: Thirty-one studies reporting a total number of 115011 patients who underwent OBCS (n = 11978) or BCS (n = 103033) were included. OBCS group showed lower risk of positive margins rate [OR 0.76, P = 0.05], re-excision rate [OR 0.72, P = 0.02], and loco-regional recurrence [OR 0.62, P = 0.03] compared to BCS group. There was no significant difference between the two groups regarding post-operative complications. CONCLUSION: Although there is a lack of level 1 evidence, the available studies clearly demonstrate superior or at least equivalent outcomes when comparing OBCS with conventional BCS. The benefits of OBCS include dealing with larger tumours, wider surgical margins and better aesthetic results for patients.

Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis.

AIMS: To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection. METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis. RESULTS: Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality. CONCLUSION: J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis.

AIMS: To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS: A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS: Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION: The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.

Sutures versus clips for skin closure following caesarean section: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

PURPOSE: To evaluate comparative outcomes of skin closure with clips and sutures after caesarean section (CS). METHODS: We conducted a systematic search of electronic information sources and bibliographic reference lists. Wound infection, wound separation, haematoma, seroma, re-admission, closure time, length of hospital stay, patient scar assessment scale (PSAS) and the observer scar assessment scale (OSAS) were the evaluated outcome parameters. RESULTS: We identified 16 randomised controlled trials reporting a total of 4926 patients who had skin closure with sutures (n = 2724) or clips (n = 2202) following CS. Use of clips was associated with a significantly higher rate of wound separation (risk ratio (RR): 2.33, P = 0.004) and longer length of hospital stay (mean difference (MD): 1.21, P = 0.03) but shorter closure time (MD: 5.35, P = 0.00001) when compared to sutures group. There was no significant difference between the two groups in the risk of wound infection (RR: 1.12, P = 0.75), haematoma formation (RR: 2.46, P = 0.23), seroma (RR: 1.17, P = 0.73), re-admission rate (RR: 1.28, P = 0.73), PSAS (MD: 0.44, P = 0.73) and OSAS (MD: 0.32, P = 0.55). Trial sequential analysis showed the meta-analysis was conclusive for wound infection, wound separation and closure time; however, it was inconclusive for length of hospital stay, PSAS and OSAS due to risk of type 2 error. CONCLUSION: This meta-analysis of best available evidence (level 1) demonstrated that although skin closure with subcuticular sutures is more time-consuming than clips, it is associated with a significantly lower risk of wound separation and shorter length of hospital stay.

Multi-modality detection of SARS-CoV-2 in faecal donor samples for transplantation and in asymptomatic emergency surgical admissions.

Background: Faecal transplantation is an evidence-based treatment for Clostridioides difficile. Patients infected with SARS-CoV-2 have been shown to shed the virus in stool for up to 33 days, well beyond the average clearance time for upper respiratory tract shedding. We carried out an analytical and clinical validation of reverse-transcriptase quantitative (RT-qPCR) as well as LAMP, LamPORE and droplet digital PCR in the detection of SARS-CoV-2 RNA in stool from donated samples for faecal microbiota transplantation (FMT), spiked samples and asymptomatic inpatients in an acute surgical unit.  Methods: Killed SARS-CoV-2 viral lysate and extracted RNA was spiked into donor stool & FMT and a linear dilution series from 10 -1 to 10 -5 and tested via RT-qPCR, LAMP, LamPORE and ddPCR against SARS-CoV-2. Patients admitted to the critical care unit with symptomatic SARS-CoV-2 and sequential asymptomatic patients from acute presentation to an acute surgical unit were also tested. Results: In a linear dilution series, detection of the lowest dilution series was found to be 8 copies per microlitre of sample. Spiked lysate samples down to 10 -2 dilution were detected in FMT samples using RTQPCR, LamPORE and ddPCR and down to 10 -1 with LAMP. In symptomatic patients 5/12 had detectable SARS-CoV-2 in stool via RT-qPCR and 6/12 via LamPORE, and in 1/97 asymptomatic patients via RT-qPCR. Conclusion: RT-qPCR can be detected in FMT donor samples using RT-qPCR, LamPORE and ddPCR to low levels using validated pathways. As previously demonstrated, nearly half of symptomatic and less than one percent of asymptomatic patients had detectable SARS-CoV-2 in stool.

Laparoscopic versus open hepatectomy for malignant liver tumours in the elderly: systematic review and meta-analysis.

To evaluate comparative outcomes of laparoscopic versus open hepatectomy for malignant liver tumours in elderly patients. A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov, and Science Direct. Comparative studies comparing laparoscopic (LH) versus open hepatectomy (OH) for both primary and metastatic malignant liver tumours in the elderly were included. Total operative time (minutes), need to perform Pringle's manoeuvre, blood loss (ml), the requirement for blood transfusion intra-operatively/post-operatively, post-operative complications, r0 resection rate, specimen resection margin (mm), re-operation rate, length of hospital stay (LOS), and 90-day mortality were the evaluated outcome parameters. Twelve studies reporting a total number of 1762 patients who underwent laparoscopic (n = 831) or open (n = 931) hepatectomy were included. OH group was associated with a significantly higher overall number of post-operative complications compared to LH (P = 0.00001). Complications such as post-operative liver failure (P = 0.02), ascites formation (P = 0.002), surgical site infection (P = 0.02), blood loss (P = 0.03), blood transfusion rate (P = 0.05), and LOS (P = 0.00001) were significantly higher in the OH group when compared to LH. There was no significant difference between the two groups in terms of total operative time (P = 0.53), bile leak (P = 0.12), r0 resection rate (P = 0.36), re-operation (P = 0.70), and 90-day mortality (P = 0.11). Laparoscopic liver resections are safe with at least equal or superior peri-operative outcomes in the elderly population, although available data regards mainly the results of minor resections. Laparoscopic major resections in the elderly population should be carefully evaluated and preferably performed in expert centres.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

AIMS: The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis. METHODS: A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters. RESULTS: Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection. CONCLUSION: Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.