Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.

BACKGROUND: Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis. METHODS: A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures. RESULTS: Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; P  = 0.21; I 2 = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; P  = 0.90; I 2 = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; P  = 0.05; I 2 = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of - 2.53 (95 %CI - 4.28 to - 0.78; P = 0.005; I 2 = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; P <  0.001; I 2 = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; P  = 0.003; I 2 = 79 %). CONCLUSIONS: EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.

Randomized double-blinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty.

OBJECTIVE: The aim of the current study was to compare the clinical outcomes of mesh fixation with fibrin sealant (FS) spray or mechanical stapling (MS) in laparoscopic total extraperitoneal hernioplasty (TEP). BACKGROUND: The most appropriate method of mesh fixation is uncertain. METHODS: Between June 2007 and June 2011, consecutive patients with primary reducible unilateral inguinal hernia who underwent day-case laparoscopic TEP were recruited. Outcome parameters included the incidence of acute and chronic pain, recurrence rates, morbidity rates, analgesic requirements, quality-of-life (QOL) scores, and direct cost. RESULTS: During the study period, 130 patients were included in the study. Patients in the MS group had significantly worse pain scores on the day after operation (P = 0.006). Analgesic requirements were similar between the 2 groups (P = 0.558). At 6 months, no significant differences in the incidence of chronic pain were observed (at rest, after coughing or cycling). The incidence of seroma formation was similar between the 2 groups (P = 0.64), and no recurrences were observed at 1 year. No differences in the QOL scores were detected. The direct cost of the entire hospitalization in the FS group was less expensive (P < 0.001). CONCLUSIONS: FS and MS are both effective methods of providing mesh fixation. FS was associated with reduced acute pain but not chronic pain. The rates of seroma formation were similar. However, the use of FS for mesh fixation was less expensive. [corrected].

Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video).

BACKGROUND: Gastrojejunal anastomosis is commonly performed for palliative management of malignant gastric outlet obstruction and bariatric surgery. Natural orifice transluminal endoscopic surgery revolutionized the surgical approach to intra-abdominal surgery. This study explored the possibility of performing gastrojejunostomy (GJ) by using a hybrid natural orifice transluminal endoscopic surgery approach. OBJECTIVE: To develop a surgical technique for the performance of transgastric endoscopic GJ (TGEJ) in a porcine model. DESIGN: Prospective series of animal experiments. SETTING: University hospital animal laboratory. ANIMALS: Thirteen female domestic pigs. INTERVENTIONS: With the animals under general anesthesia, the endoscope is passed through the gastrotomy and a segment of small bowel is retrieved into the stomach. An enterotomy is then created, and an EndoGIA stapler is introduced through an intragastric port and passed between the small bowel and stomach wall. A GJ is formed after firing of the EndoGIA stapler. The pigs are allowed to resume their diet 1 day after the operation and are allowed to survive for 2 weeks before they are euthanized. The patency of the GJ is confirmed with a repeat endoscopy, contrast study, and postmortem examination. RESULTS: A total of 13 TEGJs were performed, 11 of which were successful. The mean operative time was 53.6 +/- 45.7 minutes. The mean time for gastrotomy was 4.7 minutes, and that for GJ was 42.5 minutes. One TEGJ was converted to open surgery because of malpositioning of the intragastric port, and the other failed because the enterotomy was too extensive. Ten of 11 pigs survived for 2 weeks, and endoscopic examination with contrast study confirmed that all the gastrojejunostomies were patent. On postmortem examination, the average size of the GJ was 30 mm. LIMITATIONS: The length between duodenojejunal flexure and the site chosen to perform the GJ could not be determined. CONCLUSIONS: TEGJ is technically feasible with a patent and sizable anastomosis.