Metabolic bariatric surgery as a therapeutic option for patients with type 2 diabetes: A meta-analysis and network meta-analysis of randomized controlled trials.

AIM: To compare different types of metabolic surgery with non-surgical therapy for the treatment of type 2 diabetes (T2D). METHODS: The present network meta-analysis (NMA) includes randomized clinical trials (duration ≥ 52 weeks) comparing different surgery techniques with non-surgical therapy in diabetes patients. The primary endpoints were endpoint HbA1c, body mass index (BMI) and diabetes remission. The secondary endpoints included fasting plasma glucose, lipid profile, blood pressure, arterial hypertension and dyslipidaemia remission, quality of life and surgical adverse events. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and the Mantel-Haenzel odds ratio for categorial variables, were calculated. RESULTS: The types of surgical procedure included laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD), greater curvature plication (GCP), one-anastomosis gastric bypass (OAGB) and Duodeno-Jejunal bypass. Thirty-six trials were included. Metabolic bariatric surgery (MBS) was associated with a significantly higher reduction of HbA1c, diabetes remission and BMI compared with medical therapy. In the NMA, a significant reduction of HbA1c was observed with OAGB and SG. Complete diabetes remission significantly increased with all surgical procedures in comparison with non-surgical therapy, except for GCP. In addition, only BPD, RYGB and OAGB were associated with a significant reduction of BMI. CONCLUSIONS: MBS is an effective option for the treatment of T2D in patients with obesity. Further long-term trials of appropriate quality are needed for assessing the risk-benefit ratio in some patient cohorts, such as those with a BMI of less than 35 kg/m2 and aged older than 65 years.

Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long­term follow­up data from a Western multicenter retrospective study.

INTRODUCTION: There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice. MATERIALS AND METHODS: All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate. RESULTS: A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively. CONCLUSION: Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

Smoke Evacuation During Laparoscopic Surgery: A Problem Beyond the COVID-19 Period. A Quantitative Analysis of CO2 Environmental Dispersion Using Different Devices.

Background. The COVID-19 pandemic leads to several debates regarding the possible risk for healthcare professionals during surgery. SAGES and EAES raised the issue of the transmission of infection through the surgical smoke during laparoscopy. They recommended the use of smoke evacuation devices (SEDs) with CO2 filtering systems. The aim of the present study is to compare the efficacy of different SEDs evaluating the CO2 environmental dispersion in the operating theater. Methods. We prospectively evaluated the data of 4 group of patients on which we used different SEDs or standard trocars: AIRSEAL system (S1 group), a homemade device (S2 group), an AIRSEAL system + homemade device (S3 group), and with standard trocars and without SED (S4 group). Quantitative analysis of CO2 environmental dispersion was carried out associated to the following data in order to evaluate the pneumoperitoneum variations: a preset insufflation pressure, real intraoperative pneumoperitoneum pressure, operative time, total volume of insufflated CO2, and flow rate index. Results. 16 patients were prospectively enrolled. The [CO2] mean value was 711 ppm, 641 ppm, 593 ppm, and 761 ppm in S1, S2, S3, and S4 groups, respectively. The comparison between data of all groups showed statistically significant differences in the measured ambient CO2 concentration. Conclusion. All tested SEDs seem to be useful to reduce the CO2 environmental dispersion respect to the use of standard trocars. The association of AIRSEAL system and a homemade device seems to be the best solution combining an adequate smoke evacuation and a stable pneumoperitoneum during laparoscopic surgery.

Use of the ORBEYETM Exoscope in General Surgery: The Advent of Video-Assisted Open Surgery.

Background. Microsurgery has quickly become the "gold standard" approach for vascular surgical steps during neurosurgery. However, despite its advantages, the microscope has not been widely adopted in general surgery. A new 3D-surgical exoscope, the ORBEYETM, has been developed and introduced to some surgical specialties. Herein, we present our preliminary experience with the ORBEYETM exoscope as applied to a number of general surgical procedures. Method. Throughout February 2020, 7 patients had undergone varying surgical procedures at our institute utilizing the ORBEYETM in some of specific procedural steps where the surgeons felt that the surgery would benefit from more enhanced magnification. Upon completion, all the surgeons who had taken part in the procedure were asked if they had experienced any nausea, dizziness, or eyestrain during its use. Results. The ORBEYETM was employed in a number of surgical steps for the following procedures: throughout an inguinal hernia repair, during a duodeno-cephalo-pancreatectomy, for a subtotal gastrectomy, during para-aortic mass dissection, and during Ivor Lewis procedure. None of the surgeons involved in the procedures reported experiencing any nausea, dizziness nor eyestrain, nor any other physical discomforts. Conclusion. To the best of our knowledge, ours is the very first report on the employment of the ORBEYE exoscope during general surgery. Our experience assures us that this highly ergonomic technology with its high-resolution 4K 3D optical system allows the surgeon to perform safe and precise surgery in several dedicated steps in which adequate magnification is required with no adverse effects to the surgeon or the surgical procedure itself.

Laparoscopic resection with complete mesocolic excision for splenic flexure cancer: long-term follow-up data from a multicenter retrospective study.

BACKGROUND: Splenic flexure cancer (SFC), identified as tumors raised in the distal transverse colon and proximal descending colon, accounts for 2 to 5% of all surgically treated colorectal cancers. Despite the fact that the laparoscopic approach has become the gold standard for many colorectal procedures, it has never been extensively investigated in SFC due to lack of an agreed consensus on the appropriate operative procedure. The aim of this multicenter retrospective study is to evaluate the oncologic value of laparoscopic segmental resection with complete mesocolic excision (CME) for cancer located in the splenic flexure. METHODS: All data of consecutive patients who had undergone laparoscopic resection with CME for SFC from January 2005 to December 2017 at five different tertiary centers were retrospectively analyzed. The Kaplan-Meier (KM) test was used to assess the overall survival (OS) and the disease-free survival (DFS) rates after surgery. Univariate Cox regression was used to explore the association between OS and other independent factors. RESULTS: Recurrence was observed in 13 (11.6%) patients and a significant association between disease stage and recurrence (P < 0.001) was found with a higher proportion of stage IV patients in the recurrence group (46.1% vs. 7.1%). During a median follow-up of 43 months (range 12-149), 13 deaths occurred, all of them due to disease progression. KM curves for all stages showed an estimated survival rate of 51% at 148 months. CONCLUSION: Laparoscopic segmental resection with CME appears to be an oncologically safe and effective procedure for treatment of SFC and may be considered as a standard surgical method for elective management of the disease. In the future, routine lymph node mapping could be used to confirm this hypothesis.

Is robotic right colectomy economically sustainable? a multicentre retrospective comparative study and cost analysis.

BACKGROUND: Following the Food and Drug Administration approval, robot-assisted colorectal surgery has gained more acceptance among surgeons. One of the open issues about robotic surgery is the economic sustainability. The aim of our study is to evaluate the economic sustainability of robotic as compared to laparoscopic right colectomy for the Italian National Health System. METHODS: We performed a retrospective multicentre case-matched study including 94 patients for each group from four different Italian surgical departments. An economic evaluation gathered from a real-world data was performed to assess the sustainability of the robotic approach for right colectomy in the Italian National Health System. In particular, a differential cost analysis between the two procedures was performed. RESULTS: No statistical differences were found between the two groups for postoperative outcomes. After a careful review of the literature on the cost assessment for the operative room, medical devices and hospital stay according with our data, we estimated the followings: (a) the mean operative room cost for robotic group was 2179 ± 476 € vs. 1376 ± 322 € for laparoscopic group; (b) the mean hospital stay cost for robotic group was 3143 ± 1435 € vs. 3292 ± 1123 € for laparoscopic group; and (c) the mean cost for instruments was 6280 € for robotic group vs. 1504 € for laparoscopic group. The total mean cost of robotic right colectomy was 11,576 ± 1915 € vs. 6196 ± 1444 € for laparoscopic right colectomy. CONCLUSION: In conclusion, to date, robotic right colectomy with intracorporeal anastomosis does not provide any significant clinical advantages, which may justify the additional costs, as compared to its laparoscopic counterpart. Further evolution of robotic technology and experience may lead to a reduction of costs, especially if the robotic platform is used in an appropriate healthcare setting.

Lack of advantages of slit mesh placement during laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP): a single centre, case matched study.

BACKGROUND: During laparoscopic trans-abdominal pre-peritoneal hernia repair (TAPP) the positioning of the mesh around the spermatic cord could provide an additional anchoring point and ensure better defect closure, thereby preventing mesh movement and recurrence. The primary aim of our retrospective study was to determine if, during a TAPP procedure, an advantageous difference for mesh placement exists between the slit and the non-slit techniques in terms of recurrence rate. Secondary aims were intra and post-operative complications and the time required to return to normal activity. METHODS: From January 2010 to December 2015, data from patients who had undergone TAPPs at our Institution were prospectively collected. We performed a retrospective case control matched study of two homogenous (BMI, Age, type of hernia) groups of 100 patients who underwent respectively TAPP with no slit mesh placement (Group NS) and slit mesh placement (Group S). Statistical analysis was carried out using a SPSS 20. To compare continuous variables, an independent sample T-test was performed. A Chi-square test was employed for categorical data. RESULTS: No differences were found between the slit and non-slit groups in terms of biometric features and intra and post-operative outcomes were found to be similar in both groups as well. In particular, at mean follow-up of 57.34 ± 10.56 months for Group NS and 55.66 ± 8.61 months for Group S months only one recurrence per group was found. CONCLUSION: Our study failed to prove a superiority of the slit mesh technique over the no-slit mesh technique during TAPP. However, in light of its not being a randomized study, a subsequent, well-designed RCT would be desirable in order to better determine if the Slit mesh technique could prove to be advantageous enough to justify its routine use during the TAPP procedure.

The Use of Barbed Suture for Intracorporeal Mechanical Anastomosis During a Totally Laparoscopic Right Colectomy: Is It Safe? A Retrospective Nonrandomized Comparative Multicenter Study.

BACKGROUND: A totally laparoscopic right colectomy could be perceived as a more challenging procedure over a laparoscopic-assisted right colectomy owing to the difficulty of intracorporeal anastomosis and the closure of the enterotomy. The aim of this study is to evaluate the safety and efficacy of the barbed auto-locking absorbable suture for the closure of an anastomotic stapler-access enterotomy during a totally laparoscopic right colectomy. METHODS: From January 2010 to April 2016, data from patients who had undergone a laparoscopic right colectomy in 2 different departments of 2 institutions (the Department of General and Minimally Invasive Surgery, San Camillo Hospital in Trento and the Department of Surgical Specialties and Nephrology, University Federico II in Naples) were retrospectively analyzed. We compared the data of patients in whom the stapler-access enterotomy was closed through a conventional absorbable suture (Group A), with the data of patients in whom a stapler-access enterotomy was closed through a V-Loc 180 suture (Group B). Biometric features and intraoperative and postoperative data were collected and analyzed. RESULTS: The 2 groups (Group A: 40 patients; Group B: 40 patients) were comparable for biometric features and postoperative outcomes. The anastomosing time was lower in Group B. A statistically significant difference was noted in the mean operative time between Groups A and B (Group A = 134.92 ± 34.17; Group B = 120.92 ± 23.27, P = .035). Only one anastomotic leakage per group was recorded, each treated with an anastomosis redo. During the reoperations, we find in both groups an intact stapler-access enterotomy. CONCLUSION: On retrospective analysis, barbed suture appears to be safe and efficient for closure of the stapler-access enterotomy during totally laparoscopic right colectomy.

Laparoscopic treatment of abdominal unicentric castleman's disease: a case report and literature review.

BACKGROUND: Castleman's disease is a rare lymphoproliferative disorder of unknown etiology that most commonly presents as a mediastinal nodal mass. It is exceptionally uncommon for Castleman's disease to present in the mesentery and, only 53 cases have ever been described in the literature. Standard treatment for this lymphoproliferative disorder involving a single node is a complete "en bloc" surgical resection which has proven to be a curative approach in almost all cases without recurrence after 20 years of follow up. All 53 reported cases of mesenteric Castleman's disease, except one, were treated with laparotomy. CASE PRESENTATION: We report on a case of mesenteric Castleman's disease localized in the mesentery which is the second reported case if its kind and was treated by a laparoscopic-assisted procedure. Our female patient had an uneventful postoperative course and was discharged in the 5th post-operative day. No signs of recurrence were present as evidenced by physical examination and total body CT scan 24 months after the operation. We compare our case with the other reported cases in which Castleman's disease presented as an isolated mass in the abdomen. CONCLUSION: Although a rare disease, Unicentric Castleman's disease should always be considered when a solid asymptomatic abdominal mass is occasionally presented. The laparoscopic approach (LA) allows for the achievement of better results than open surgery, including a reduction in postoperative pain and length of hospital stay. In cases of masses of an uncertain nature, LA must be considered the last diagnostic tool and the first treatment one.

Comparison between a Direct-Flow SPR Immunosensor for Ampicillin and a Competitive Conventional Amperometric Device: Analytical Features and Possible Applications to Real Samples.

In this research, we developed a direct-flow surface plasmon resonance (SPR) immunosensor for ampicillin to perform direct, simple, and fast measurements of this important antibiotic. In order to better evaluate the performance, it was compared with a conventional amperometric immunosensor, working with a competitive format with the aim of finding out experimental real advantages and disadvantages of two respective methods. Results showed that certain analytical features of the new SPR immunodevice, such as the lower limit of detection (LOD) value and the width of the linear range, are poorer than those of a conventional amperometric immunosensor, which adversely affects the application to samples such as natural waters. On the other hand, the SPR immunosensor was more selective to ampicillin, and measurements were more easily and quickly attained compared to those performed with the conventional competitive immunosensor.

Further development on DMFC device used for analytical purpose: real applications in the pharmaceutical field and possible in biological fluids.

The analytical research devoted to the utilization of the direct methanol fuel cell (DMFC) for analytical purposes has been continued. The research reported in this paper concerns two points, one of which was the possibility of improving the features, from the analytical point of view, of a catalytic fuel cell for methanol and ethanol, by introducing an enzyme, immobilized into a dialysis membrane small bag, in the anodic area of the fuel cell. This objective has been fully achieved, particularly using the enzyme alcohol dehydrogenase, which has increased the sensitivity of the method and reduced dramatically the response time of the cell. The second point concerned the opportunity to determine two particular antibiotics having an alcohol functional group in their molecule, that is, imipenem and chloramphenicol. Also, this goal has been reached, even if the sensitivity of the method is not so high. Graphical abstract Imipenem and Chloramphenicol determination using the DMFC and Ethanol determination using the enzymatic DMFC.

Characterization of childhood trauma, hippocampal mediation and Cannabis use in a large dataset of psychosis and non-psychosis individuals.

BACKGROUND: Cannabis use (CA) and childhood trauma (CT) independently increase the risk of earlier psychosis onset; but their interaction in relation to psychosis risk and association with endocannabinoid-receptor rich brain regions, i.e. the hippocampus (HP), remains unclear. The objective was to determine whether lower age of psychosis onset (AgePsyOnset) is associated with CA and CT through mediation by the HP volumes, and genetic risk, as measured by schizophrenia polygene scores (SZ-PGRS). METHODS: Cross-sectional, case-control, multicenter sample from 5 metropolitan US regions. Participants (n = 1185) included 397 controls not affected by psychosis (HC); 209 participants with bipolar disorder type-1; 279 with schizoaffective disorder; and 300 with schizophrenia (DSM IV-TR). CT was assessed using the Childhood Trauma Questionnaire (CTQ); CA was assessed by self-reports and trained clinical interviewers. Assessment included neuroimaging, symptomatology, cognition and calculation of the SZ polygenic risk score (SZ-PGRS). RESULTS: In survival analysis, CT and CA exposure interact to be associated with lower AgePsyOnset. At high CT or CA, CT or CA are individually sufficient to affect AgePsyOnset. CT relation with AgePsyOnset is mediated in part by the HP in CA users before AgePsyOnset. CA before AgePsyOnset is associated with higher SZ-PGRS and correlated with younger age at CA usage. DISCUSSION: CA and CT interact to increase risk when moderate; while severe CT and/or CA abuse/dependence are each sufficient to affect AgePsyOnset, indicating a ceiling effect. Probands with/out CA before AgePsyOnset differ on biological variables, suggesting divergent pathways to psychosis. FUNDING: MH077945; MH096942; MH096913; MH077862; MH103368; MH096900; MH122759.

Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis.

BACKGROUND: Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are the most used laparoscopic techniques for inguinal hernia treatment. However, many studies have shown that laparoscopic hernia repair compared with open hernia repair (OHR) may offer less pain and shorter convalescence. Few studies compared the clinical efficacy between TEP and TAPP technique. The purpose of this study is to provide a comparison between TEP and TAPP for inguinal hernia repair to show the best approach. METHODS: We performed an indirect comparison between TEP and TAPP techniques by considering only randomized, controlled trials comparing TEP with OHR and TAPP with OHR in a network meta-analysis. We considered the following outcomes: operative time, postoperative complications, hospital stay, postoperative pain, time to return to work, and recurrences. RESULTS: The two techniques improved some short outcomes (such as time to return to work) with respect to OHR. In the network meta-analysis, TEP and TAPP were equivalent for operative time, postoperative complications, postoperative pain, time to return to work, and recurrences, whereas TAPP was associated with a slightly longer hospital stay compared with TEP. CONCLUSIONS: TEP and TAPP improved clinical outcomes compared with OHR, but the network meta-analysis showed that TEP and TAPP efficacy is equivalent. TAPP was associated with a slightly longer hospital stay compared with TEP.

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB).

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

SIMPCA: a framework for rotating and sparsifying principal components.

We propose an algorithmic framework for computing sparse components from rotated principal components. This methodology, called SIMPCA, is useful to replace the unreliable practice of ignoring small coefficients of rotated components when interpreting them. The algorithm computes genuinely sparse components by projecting rotated principal components onto subsets of variables. The so simplified components are highly correlated with the corresponding components. By choosing different simplification strategies different sparse solutions can be obtained which can be used to compare alternative interpretations of the principal components. We give some examples of how effective simplified solutions can be achieved with SIMPCA using some publicly available data sets.

Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study.

Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.

Achieving the Learning Curve in Laparoscopic Inguinal Hernia Repair by Tapp: A Quality Improvement Study.

Background: More than 20 million patients worldwide undergo groin hernia repair annually. Every year more than 800,000 inguinal hernia repairs are performed in the United States alone. Since the first report by Ger et al. in 1990, laparoscopic inguinal hernia repair has gained wide acceptance due to its many advantages with more than 20% of inguinal hernias treated by this approach. The aim of our study is to estimate the number of cases needed over the course of a trainee's learning curve period to achieve stabilization of operating time and intra and post-operative complication rates when performing laparoscopic transabdominal preperitoneal hernia repair (TAPP). Methods: We analyzed data from the first 100 TAPP procedures performed by two different trainees (trainee A & B) and compared it with a homogeneous group of 100 procedures performed by a senior surgeon. Two tests were used to evaluate completion of the learning curve: the Cumulative Sum (CUSUM) and KPSS tests. The CUSUM test evaluated when the trainee's operative time became consistently similar to that of the senior surgeon, while the KPSS test evaluated when the trainee's operative time became stationary. Results: No differences in intra and post-operative data were noted between the three groups. The CUSUM test showed that trainee A completed his learning curve after 60 procedures, while trainee B completed it after 65 procedures. The KPSS test showed that the operative time stabilized after 20 procedures for trainee A and after 50 procedures for trainee B, respectively. Conclusions: Our evaluation shows that both trainees fully completed their learning curves for the TAPP after 65 procedures, providing us with a parameter which can be taken into consideration when establishing the minimum volume necessary to guarantee correct training in laparoscopic inguinal hernia repair by a TAPP technique.

Is Shouldice the best NON-MESH inguinal hernia repair technique? A systematic review and network metanalysis of randomized controlled trials comparing Shouldice and Desarda.

BACKGROUND: Current guidelines state that the Shouldice technique has lower recurrence rates than other suture repairs and therefore is strongly recommended in non-mesh inguinal hernia repair. Recently a new tissue repair technique has been proposed by Desarda and studied in trials against Lichtenstein technique. METHODS: The present study was performed according to the PRISMA Statement for Network Meta-analysis and the AMSTAR 2 checklist. The method of network meta-analysis was chosen to evaluate randomized controlled trial published on tissue repair and comparing Lichtenstein respectively with Desarda and Shouldice techniques. The following parameters: operative time, recurrence, complications (general, intraoperative, Surgical Surgical Site Occurrences), VAS score on postoperative day 1, numbness, chronic pain and return to daily activities. RESULTS: Fourteen RCTs, involving 2791 patients, fulfilled the inclusion criteria and were selected for final analysis. The anchored indirect treatment comparison showed that Desarda's technique requires a significantly shorter operative time (MD: -12.9 min; 95% CI: -20.6 to -5.2) and has a quicker recovery (MD: -6.6 days; 95% CI: -11.7 to -1.4). Outcomes concerning intraoperative complications, early postoperative pain, seroma/hematoma, hydrocele and infection rates, recurrence, numbness and chronic pain were similar among the two techniques. CONCLUSIONS: Desarda's hernia repair can be a valuable alternative to Shouldice technique for the treatment of primary inguinal hernia repair if a non-mesh technique is chosen, because of its reproducibility and quicker postoperative recovery. We recommend performing well designed prospective studies comparing both techniques directly.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery.

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences.

BACKGROUND: The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS: The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS: The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION: The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.