To wean or not to wean: proton pump inhibitor management after anti-reflux surgery amongst foregut experts.

BACKGROUND: Most patients undergoing anti-reflux surgery (ARS) have a history of preoperative proton pump inhibitor (PPI) use. It is well-established that ARS is effective in restoring the anti-reflux barrier, eliminating the ongoing need for costly PPIs. Current literature lacks objective evidence supporting an optimal postoperative PPI cessation or weaning strategy, leading to wide practice variations. We sought to objectively gauge current practice and opinion surrounding the postoperative management of PPIs among expert foregut surgeons and gastroenterologists in the United States. METHODS: We created a survey of postoperative PPI management protocols, with an emphasis on discontinuation and timing of PPI cessation, and aimed to determine what factors played a role in the decision-making. An electronic survey tool (Qualtrics XM, Qualtrics, Provo, UT) was used to distribute the survey and to record the responses anonymously for a period of three months. RESULTS: The survey was viewed 2658 times by 373 institutions and shared with 644 members. In total, 121 respondents participated in the survey and 111 were surgeons (92%). Fifty respondents (42%) always discontinue PPIs immediately after ARS. Of the remaining 70 respondents (58%), 46% always wean or taper PPIs postoperatively and 47% wean or taper them selectively. The majority (92%) of practitioners taper within a 3-month period postoperatively. Five respondents never discontinue PPIs after ARS. Overall, only 23 respondents (19%) stated their protocol is based on medical literature or evidence-based medicine. Instead, decision-making is primarily based on anecdotal evidence/personal preference (42%, n = 50) or prior training/mentors (39%, n = 47). CONCLUSIONS: There are two major protocols used for PPI discontinuation after ARS: Nearly half of providers abruptly stop PPIs, while just over half gradually tapers them, most often in the early postoperative period. These decisions are primarily driven by institutional practices and personal preferences, underscoring the need for evidence-based recommendations.

Single-port versus multi-port laparoscopic and robotic inguinal hernia repair: a systematic review and network meta-analysis.

BACKGROUND: The evolution of minimally invasive surgery has transformed inguinal hernia repair (IHR). The innovative single-port technique reduces the number of surgical incisions. However, the benefits of single-port IHR remain controversial. Our systematic review and network meta-analysis assess the efficacy and clinical outcomes of single-port laparoscopic inguinal hernia repair (SPL-IHR), multi-port laparoscopic inguinal hernia repair (MPL-IHR), single-port robotic inguinal hernia repair (SPR-IHR), and multi-port robotic inguinal hernia repair (MPR-IHR). METHODS: A comprehensive search was conducted in PubMed, EMBASE, Cochrane, and Ovid for articles published before January 2024, focusing on complication rates, recurrence, seroma, hematoma, operative time, post-operative pain, and cosmetic outcomes of laparoscopic or robotic IHR. Both extraperitoneal (TEP) and transabdominal (TAPP) approaches were analyzed using MetaInsight. MPL-TAPP was used as the standard for comparison. RESULTS: Thirty-seven studies, including 5,038 patients, 36.92% (1,860 patients) underwent MPL-TEP, 23.64% (1,191 patients) SPL-TEP, 22.23% (1,120 patients) MPR-TAPP, 10.08% (508 patients) MPL-TAPP, 5.40% (272 patients) SPL-TAPP, and 1.73% (87 patients) SPR-TAPP. There were no significant differences in the rates of post-operative complications, hernia recurrence, hematoma, or seroma among the techniques when compared to MPL-TAPP. For secondary outcomes, MPR-TAPP significantly increased the operative time for unilateral hernia repair by a mean difference (MD) of 10.60 min [95% CI: 2.16-19.04]. Conversely, for bilateral hernia repair, there was no significant difference. Post-operative pain was significantly higher for MPL-TEP and SPL-TEP, with MDs of 1.44 [95% CI: 0.43 to 2.44] and 1.22 [95% CI: 0.18 to 2.26], respectively. SPL-TEP was significantly favored in cosmetic outcomes over MPL-TEP, with an MD of 0.65 [95% CI: 0.07 to 1.24]. CONCLUSION: In our network meta-analysis, the risk of post-operative complications, including recurrence, hematoma, and seroma, does not significantly vary among single-port and multi-port laparoscopic or robotic techniques. This suggests that surgical technique selection can rely on surgeon expertise and resource availability, without compromising outcomes.