Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis.

BACKGROUND: Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE: Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS: Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS: Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS: Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.

Effect of complete mesocolic excision (cme) on long-term survival after right colectomy for cancer: multivariate meta-analysis and restricted mean survival time estimation.

INTRODUCTION: Debate exists concerning the impact of complete mesocolic excision (CME) on long-term oncological outcomes. The aim of this review was to condense the updated literature and assess the effect of CME on long-term survival after right colectomy for cancer. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched through July 2023. The included studies evaluated the effect of CME on survival. The primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. GRADE methodology was used to summarize the certainty of evidence. RESULTS: Ten studies (3665 patients) were included. Overall, 1443 (39.4%) underwent CME. The RMSTD analysis shows that at 60-month follow-up, stage I-III CME patients lived 2.5 months (95% CI 1.1-4.1) more on average compared with noCME patients. Similarly, stage III patients that underwent CME lived longer compared to noCME patients at 55-month follow-up (6.1 months; 95% CI 3.4-8.5). The time-dependent HRs analysis for CME vs. noCME (stage I-III disease) shows a higher mortality hazard in patients with noCME at 6 months (HR 0.46, 95% CI 0.29-0.71), 12 months (HR 0.57, 95% CI 0.43-0.73), and 24 months (HR 0.73, 95% CI 0.57-0.92) up to 27 months. CONCLUSIONS: This study suggests that CME is associated with unclear OS benefit in stage I-III disease. Caution is recommended to avoid overestimation of the effect of CME in stage III disease since the marginal benefit of a more extended resection may have been influenced by tumor biology/molecular profile and multimodal adjuvant treatments.

Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination.

BACKGROUND: Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. RESULTS: Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31). CONCLUSIONS: This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.

Short-term outcomes of different esophagojejunal anastomotic techniques during laparoscopic total gastrectomy: a network meta-analysis.

BACKGROUND: Different techniques have been described for esophagojejunostomy (EJ) during laparoscopic total gastrectomy (LTG) for gastric cancer. Linear stapled techniques include overlap (OL) and functional end-to-end anastomosis (FEEA) while single staple technique (SST), hemi-double staple technique (HDST), and OrVil® are circular stapled approaches. Nowadays, the choice among techniques for EJ depends on operating surgeon personal preference. PURPOSE: To compare short-term outcomes of different EJ techniques during LTG. METHODS: Systematic review and network meta-analysis. OL, FEEA, SST, HDST, and OrVil® were compared. Primary outcomes were anastomotic leak (AL) and stenosis (AS). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to measure relative inference. RESULTS: Overall, 3177 patients (20 studies) were included. The technique for EJ was SST (n = 1026; 32.9%), OL (n = 826; 26.5%), FEEA (n = 752; 24.1%), OrVil® (n = 317; 10.1%), and HDST (n = 196; 6.4%). AL was comparable for OL vs. FEEA (RR = 0.82; 95% CrI 0.47-1.49), OL vs. SST (RR = 0.55; 95% CrI 0.27-1.21), OL vs. OrVil® (RR = 0.54; 95% CrI 0.32-1.22), and OL vs. HDST (RR = 0.65; 95% CrI 0.28-1.63). Similarly, AS was similar for OL vs. FEEA (RR = 0.46; 95% CrI 0.18-1.28), OL vs. SST (RR = 0.89; 95% CrI 0.39-2.15), OL vs. OrVil® (RR = 0.36; 95% CrI 0.14-1.02), and OL vs. HDST (RR = 0.61; 95% CrI 0.31-1.21). Anastomotic bleeding, time to soft diet resumption, pulmonary complications, hospital length of stay, and mortality were comparable while operative time was reduced for FEEA. CONCLUSIONS: This network meta-analysis shows similar postoperative AL and AS risk when comparing OL, FEEA, SST, HDST, and OrVil® techniques. Similarly, no differences were found for anastomotic bleeding, operative time, soft diet resumption, pulmonary complications, hospital length of stay and 30-day mortality.

Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes.

BACKGROUND: Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm2, a mesh is used to reinforce the repair. OBJECTIVE: The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes. METHODS: Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed. RESULTS: Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm2 while 26 patients had an HSA greater than 4 cm2. The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved. CONCLUSIONS: The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis.

BACKGROUND: Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS: Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). CONCLUSIONS: LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Techniques for reconstruction after distal gastrectomy for cancer: updated network meta-analysis of randomized controlled trials.

BACKGROUND: The choice of the best reconstruction technique after distal gastrectomy (DG) remains controversial and still not defined. The purpose was to perform a comprehensive evaluation within the major type of intestinal reconstruction after DG for gastric cancer. METHODS: Systematic review and network meta-analyses of randomized controlled trials (RCTs) to compare Billroth I (BI), Billroth II (BII), Billroth II Braun (BII Braun), Roux-en-Y (RY), and Uncut Roux-en-Y (URY). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures while 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Ten RCTs (1456 patients) were included. Of these, 448 (33.7%) underwent BI, 220 (15.1%) BII, 114 BII Braun (7.8%), 533 (36.6%) RY, and 141 URY (9.6%). No significant differences were found among treatments for 30-day mortality, anastomotic leak, anastomotic stricture, and overall complications. At 12-month follow-up, RY was associated with a significantly reduced risk of remnant gastritis compared to BI (RR=0.56; 95% Crl 0.35-0.76) and BII reconstruction (RR=0.47; 95% Crl 0.22-0.97). Similarly, despite the lack of statistical significance, RY seems associated with a trend toward reduced endoscopically proven esophagitis compared to BI (RR=0.58; 95% Crl 0.24-1.51) and bile reflux compared to BI (RR=0.48; 95% Crl 0.17-1.41), BII (RR=0.74; 95% Crl 0.20-2.81), and BII Braun (RR=0.65; 95% Crl 0.30-1.43). CONCLUSIONS: This network meta-analysis shows that there are five main options for intestinal anastomosis after DG. All techniques seem equally safe with comparable anastomotic leak, anastomotic stricture, overall morbidity, and short-term outcomes. In the short-term follow-up (12 months), RY seems associated with a reduced risk of remnant gastritis and a trend toward a reduced risk of bile reflux and esophagitis.

Treatment of Inguinal Hernia: Systematic Review and Updated Network Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Despite the advent of innovative surgical platforms and operative techniques, a definitive indication of the best surgical option for the treatment of unilateral primary inguinal hernia remains unsettled. Purpose was to perform an updated and comprehensive evaluation within the major approaches to inguinal hernia. METHODS: Systematic review and network meta-analyses of randomized controlled trials (RCTs) compare Lichtenstein tension-free repair, laparoscopic transabdominal preperitoneal (TAPP) repair, and totally extraperitoneal repair (TEP). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Thirty-five RCTs (7777 patients) were included. Overall, 3496 (44.9%) underwent Lichtenstein, 1269 (16.3%) TAPP, and 3012 (38.8%) TEP repair. The Visual Analogue Scale (VAS) was significantly lower for minimally invasive repair at <12 hours, 24 hours, and 48 hours. Postoperative chronic pain [TAPP vs Lichtenstein (RR = 0.36; 95% CrI 0.15-0.81) and TEP vs Lichtenstein (RR = 0.36; 95% CrI 0.21-0.54)] and return to work/activities [TAPP vs Lichtenstein (WMD = -3.3; 95% CrI -4.9 to -1.8) and TEP vs Lichtenstein (WMD = -3.6; 95% CrI -4.9 to -2.4)] were significantly reduced for minimally invasive approaches. Wound hematoma and infection were significantly reduced for minimally invasive approaches, whereas no differences were found for seroma, hernia recurrence, and hospital length of stay. CONCLUSIONS: Minimally invasive TAPP and TEP repair seem associated with significantly reduced early postoperative pain, return to work/activities, chronic pain, hematoma, and wound infection compared to the Lichtenstein tension-free repair. Hernia recurrence, seroma, and hospital length of stay seem similar across treatments.

Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis.

INTRODUCTION: The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer. MATERIALS AND METHODS: Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted. RESULTS: Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0-22.0%), 1.4% (95% CI = 0.8-2.2%), 35% (95% CI = 20.0-54.0%), and 5.0% (95% CI = 3.0-8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0-21.6%). CONCLUSIONS: Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.

Magnetic sphincter augmentation device removal: surgical technique and results at medium-term follow-up.

BACKGROUND: The magnetic sphincter augmentation (MSA) device has become a common option for the treatment of gastroesophageal reflux disease (GERD). Knowledge of MSA-related complications, indications for removal, and techniques are puzzled. With this study, we aimed to evaluate indications, techniques for removal, surgical approach, and outcomes with MSA removal. METHODS: This is an observational singe-center study. Patients were followed up regularly with endoscopy, pH monitoring, and assessed for specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and generic short-form 36 (SF-36) quality of life. RESULTS: Five patients underwent MSA explant. Four patients were males and the median age was 47 years (range 44-55). Heartburn, epigastric/chest pain, and dysphagia were commonly reported. The median implant duration was 46 months (range 31-72). A laparoscopic approach was adopted in all patients. Intraoperative findings included normal anatomy (40%), herniation in the mediastinum (40%), and erosion (20%). The most common anti-reflux procedures were Dor (n = 2), Toupet (n = 2), and anterior partial fundoplication (n = 1). The median operative time was 145 min (range 60-185), and the median hospital length of stay was 4 days (range 3-6). The median postoperative follow-up was 41 months (range 12-51). At the last follow-up, 80% of patients were off PPI; the GERD-HRQL and SF-36 questionnaire were improved with DeMeester score and esophageal acid exposure normalization. CONCLUSION: The MSA device can be safely explanted through a single-stage laparoscopic procedure. Tailoring a fundoplication, according to preoperative patient symptoms and intraoperative findings, seems feasible and safe with a promising trend toward improved symptoms and quality of life.

Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is frequently seen in patients with systemic sclerosis (SSc). Long-standing GERD may cause esophagitis, long-segment strictures, and Barrett's esophagus and may worsen pre-existing pulmonary fibrosis with an increased risk of end-stage lung disease. Surgical treatment of recalcitrant GERD remains controversial. The purpose of this systematic review was to summarize the current data on surgical treatment of recalcitrant GERD in SSc patients. MATERIALS AND METHODS: A systematic literature review according to PRISMA and MOOSE guidelines. PubMed, EMBASE, and Web of Science databases were consulted. RESULTS: A total of 101 patients were included from 7 studies. The age ranged from 34 to 61 years and the majority were females (73.5%). Commonly reported symptoms were heartburn (92%), regurgitation (77%), and dysphagia (74%). Concurrent pulmonary disease was diagnosed in 58% of patients. Overall, 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB), and 6 (5.9%) esophagectomy. The postoperative follow-up ranged from 12 to 65 months. Recurrent symptoms were described in up to 70% and 30% of patients undergoing fundoplication and RYGB, respectively. Various symptoms were reported postoperatively depending on the type of surgical procedures, anatomy of the valve, need for esophageal lengthening, and follow-up. CONCLUSIONS: The treatment of recalcitrant GERD in SSc patients is challenging. Esophagectomy should be reserved to selected patients. Minimally invasive RYGB appears feasible and safe with promising preliminary short-term results. Current evidence is scarce while a definitive indication about the most appropriate surgical treatment is lacking.

Laparoscopic Toupet Fundoplication for the Treatment of Laryngopharyngeal Reflux: Results at Medium-Term follow-Up.

BACKGROUND: The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up. MATERIALS AND METHODS: Observational cohort study (2015-2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) validate questionnaires at baseline and during follow-up. RESULTS: Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR-HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores "voice," "cough," "throat" and "swallow" showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved (p < 0.001). CONCLUSIONS: LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients' quality of life perception up to 3-year follow-up.

Semi-prone video-assisted thoracoscopy for the treatment of large infracarinal traction diverticula.

BACKGROUND: Large middle-third esophageal diverticula are rare. Thoracotomy has been proposed as mainstay of treatment; however, minimally invasive resection through lateral or prone position thoracoscopy has been described. METHODS: The technical aspects of the novel semi-prone minimally invasive thoracoscopy (spVATS) in the management of large (> 5 cm) infracarinal traction diverticula are described. Operative outcomes, pre- and postoperative symptoms (Eckardt score) and quality of life (Short-Form 36) are analyzed. RESULTS: Four symptomatic patients underwent spVATS for traction midesophageal diverticula. The median age was 59 years and 75% were males. The median diverticulum size was 7.0 cm (range 5.5-8). The median preoperative Eckardt score was 8.4 (range 5-10), and the overall incidence of respiratory symptoms was 50%. Esophageal manometry was performed in three patients with no evidence of underlying motility disorders. The median operative time was 149 min (range 125-175). No intraoperative complications or open conversions occurred. Postoperative morbidity and mortality were 25% and 0%, respectively. The median hospital length of stay was 7.5 days (range 6-10). The median postoperative follow-up was 22 months (range 5-35). At the last follow-up, there was a significant improvement of patients' symptoms (p = 0.024) and quality of life (p < 0.05) with complete resolution of respiratory symptoms. CONCLUSION: In summary, spVATS seems a valuable approach to treat large midesophageal traction diverticula in centers experienced with minimally invasive esophageal surgery. Further studies are needed to validate the advantages and promising outcomes of the spVATS providing more robust evidence on the treatment of this rare clinical entity.

Minimally-Invasive Myotomy: Percutaneous Laparoscopic Surgical Approach for Achalasia.

The laparoscopic approach of the upper gastrointestinal tract is considered the gold standard for the treatment of functional benign esophageal disorders since 1990. In recent years, many efforts have been made to minimize the abdominal wall's trauma to reduce postoperative pain and to obtain a prompt return to daily activities, as well as improve cosmetic results of surgery. The progressive development of novel surgical devices has allowed for the introduction of new minimally-invasive surgical techniques. Criticism of the single-incision laparoscopic surgery includes a modification of surgical technique and an increased incidence of wound-related complications, such as infections and incisional hernia. We present our early experience using the new MiniLap® Percutaneous Surgical System (Teleflex Incorporated, Wayne, Pennsylvania) to perform a two-trocars laparoscopic percutaneous-assisted esophageal Heller myotomy. We demonstrate that the use of percutaneous instruments was not inferior in terms of clinical outcomes as compared to the standard technique, while improving cosmetic results and reducing trocar-related abdominal pain.

Feasibility and outcomes regarding open and laparoscopic radical prostatectomy in patients with previous synthetic mesh inguinal hernia repair: meta-analysis and systematic review of 7,497 patients.

INTRODUCTION: The purpose of this article is to contribute information to the interpretation of the feasibility and outcomes regarding open, laparoscopic and robotic strategies of radical prostatectomy in patients with previous synthetic mesh inguinal hernia repair. MATERIALS AND METHODS: A bibliographic search covering the period from January 1980 to September 2012 was conducted in PubMed, MEDLINE and EMBASE. Database searches yielded 28 references. This analysis is based on the eleven studies that fulfilled the predefined criteria. RESULTS: A total of 7,497 patients were included. In the study group, there were 462 patients. The surgical prostatectomy techniques were open in five studies, laparoscopic in three and robotic in the remaining three. The control group consisted in 7,035 patients. The comparison of the open procedure performed in patients with a previous mesh herniorrhaphy and controls shows that the number of lymph nodes removed resulted significantly lower and hospital stay with catheterization time results statistically longer. The comparison of the laparoscopic procedure does not evidence a statistically significant difference in terms of blood loss, operative time and catheterization time, while the comparison with the robotic group could not be performed for the lack of data. CONCLUSION: All patients need an adequate informed consent regarding the multitude of aspects which may be influenced by the mesh such as the possibility of hernia recurrence, mesh infection, need for mesh explantation, possibility of mesh erosion into the bowel or bladder, bladder neck contractures or postoperative urinary incontinence and a compromised nodal staging.

Impact of pulmonary complications following esophagectomy on long-term survival: multivariate meta-analysis and restricted mean survival time assessment.

Pulmonary complications (PC) are common after esophagectomy and their impact on long-term survival is not defined yet. The present study aimed to assess the effect of postoperative PCs on long-term survival after esophagectomy for cancer. Systematic review of the literature through February 1, 2023, was performed. The included studies evaluated the effect of PC on long-term survival. Primary outcome was long-term overall survival (OS). Cancer-specific survival (CSS) and disease-free survival (DFS) were secondary outcomes. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. Eleven studies were included (3423 patients). Overall, 674 (19.7%) patients developed PC. The RMSTD analysis shows that at 60-month follow-up, patients not experiencing PC live an average of 8.5 (95% CI 6.2-10.8; p < 0.001) months longer compared with those with PC. Similarly, patients not experiencing postoperative PC seem to have significantly longer CSS (8 months; 95% CI 3.7-12.3; p < 0.001) and DFS (5.4 months; 95% CI 1.6-9.1; p = 0.005). The time-dependent HRs analysis shows a reduced mortality hazard in patients without PC at 12 (HR 0.6, 95% CI 0.51-0.69), 24 (HR 0.64, 95% CI 0.55-0.73), 36 (HR 0.67, 95% CI 0.55-0.79), and 60 months (HR 0.69, 95% CI 0.51-0.89). This study suggests a moderate clinical impact of PC on long-term OS, CSS, and DFS after esophagectomy. Patients not experiencing PC seem to have a significantly reduced mortality hazard up to 5 years of follow-up.