[Laparoscopic Heller Myotomy in the Treatment of Achalasia]. / Laparoskopische Heller-Myotomie zur Therapie der Achalasie.

BACKGROUND: Achalasia refers to a primary oesophageal motility disorder characterised by the absence of peristalsis and incomplete or complete lack of relaxation of the lower oesophageal sphincter. The cardinal symptom is dysphagia. The therapeutic goal is surgical or interventional repair of the oesophageal outflow tract at the level of the oesophagogastric junction. INDICATION: We present the case of a 24-year-old patient with dysphagia accompanied by regurgitations, odynophagia as well as an unintentional weight loss over two years. METHODS: The video describes the preoperative imaging as well as endoscopic findings and demonstrates the technique of laparoscopic Heller myotomy followed by Dor fundoplication. CONCLUSIONS: Concerning the therapy of classic achalasia, laparoscopic Heller myotomy followed by Dor fundoplication - despite controversies regarding peroral endoscopic myotomy as an alternative therapeutic option - can be considered as an established standard procedure.

Single-incision surgery trocar-site hernia: an updated systematic review meta-analysis with trial sequential analysis by the Minimally Invasive Surgery Synthesis of Interventions Outcomes Network (MISSION).

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a new technique that aims to minimize abdominal wall trauma and improve cosmesis. Concerns have been raised about the risk of trocar-site hernia following SILS. This study aims to assess the risk of trocar-site hernia following SILS compared to conventional laparoscopic surgery, and investigate whether current evidence is conclusive. METHODS: We performed a systematic search of MEDLINE, AMED, CINAHL, CENTRAL, and OpenGrey. We considered randomized clinical trials comparing the risk of trocar-site hernia with SILS and conventional laparoscopic surgery. Pooled odds ratios with 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method. Trial sequential analysis using the Land and DeMets method was performed to assess the possibility of type I error and compute the information size. RESULTS: Twenty-three articles reporting a total of 2471 patients were included. SILS was associated with higher odds of trocar-site hernia compared to conventional laparoscopic surgery (odds ratio 2.37, 95% CI 1.25-4.50, p = 0.008). There was no evidence of between-study heterogeneity or small-study effects. The information size was calculated at 1687 patients and the Z-curve crossed the O'Brien-Fleming α-spending boundaries at 1137 patients, suggesting that the evidence of higher risk of trocar-site hernia with SILS compared to conventional laparoscopic surgery can be considered conclusive. CONCLUSIONS: Single-incision laparoscopic procedures through the umbilicus are associated with a higher risk of trocar-site hernia compared to conventional laparoscopic surgery.

Single-incision laparoscopic cholecystectomy with curved versus linear instruments assessed by systematic review and network meta-analysis of randomized trials.

BACKGROUND: Single-incision laparoscopic surgery poses significant ergonomic limitations. Curved instruments have been developed in order to address the issue of lack of triangulation. Direct comparison between single-incision laparoscopic surgeries with conventional linear and curved instruments has not been performed to date. METHODS: MEDLINE, CENTRAL and OpenGrey were searched to identify relevant randomized trials. A network meta-analysis was applied to compare operative risks, conversion, duration of surgery and the need for placement of an adjunct trocar in single-incision laparoscopic cholecystectomy with linear and curved instruments. The random-effects model was applied for two sets of comparisons, with conventional laparoscopic cholecystectomy as the reference treatment. Odds ratios, mean differences and 95% confidence intervals were calculated. RESULTS: Twenty-three randomized trials encompassing 1737 patients were included. The use of curved instruments was associated with increased operative time (mean difference 32.53 min, 95% CI 24.23-40.83) and higher odds for the use of an adjunct trocar (odds ratio 22.81, 95% CI 16.69-28.94) compared to the use of linear instruments. Perioperative risks could not be comparatively assessed due to the low number of events. CONCLUSION: Single-incision laparoscopic cholecystectomy with curved instruments may be associated with an increased level of operative difficulty, as reflected by the need for auxiliary measures for exposure and increased operative time as compared to the use of linear instruments. Current instrumentation requires further improvement, tailored to the features of single-incision laparoscopic surgery (CRD42015015721).

Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients.

BACKGROUND: Increasing life expectancy requires specific attention on geriatric patients. Data support a potential reduction of surgical morbidity for patients undergoing laparoscopic surgery as compared to conventional surgery. The aim of this study was to investigate the comparative effect of laparoscopic and open colorectal surgery on geriatric patients. METHODS: A systematic review of electronic information sources was undertaken. Studies that provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open colorectal surgery, were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was independently appraised by two reviewers. Random effects model was applied to synthesize outcome data. RESULTS: Twenty-seven articles providing data for 66,592 patients were included in the analysis. Patients undergoing laparoscopic surgery had a decreased risk for mortality (2.2 vs. 5.4 %; OR 0.55, 95 % CI 0.44-0.67), overall morbidity (19.3 vs. 26.7 %; OR 0.54, 95 % CI 0.46-0.63), cardiac (4.7 vs. 7.7 %; OR 0.60, 95 % CI 0.39-0.92) and respiratory complications (3.9 vs. 6.3 %; OR 0.67, 95 % CI 0.47-0.95). Sensitivity analysis including reports with similar age, American Society of Anesthesiologists score and/or similar prevalence of cardiopulmonary morbidity between the laparoscopic and the open treatment arm validated the outcome estimates of the primary analysis. CONCLUSIONS: This analysis supports a substantial benefit for elderly patients undergoing laparoscopic in comparison with open colorectal surgery. The comparative effect of either approach on geriatric patients with pulmonary and cardiac comorbidities is a subject of further investigation.

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications.

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

A systematic review and analysis of factors associated with methodological quality in laparoscopic randomized controlled trials.

Several methods for assessment of methodological quality in randomized controlled trials (RCTs) have been developed during the past few years. Factors associated with quality in laparoscopic surgery have not been defined till date. The aim of this study was to investigate the relationship between bibliometric and the methodological quality of laparoscopic RCTs. The PubMed search engine was queried to identify RCTs on minimally invasive surgery published in 2012 in the 10 highest impact factor surgery journals and the 5 highest impact factor laparoscopic journals. Eligible studies were blindly assessed by two independent investigators using the Scottish Intercollegiate Guidelines Network (SIGN) tool for RCTs. Univariate and multivariate analyses were performed to identify potential associations with methodological quality. A total of 114 relevant RCTs were identified. More than half of the trials were of high or acceptable quality. Half of the reports provided information on comparative demo graphic data and only 21% performed intention-to-treat analysis. RCTs with sample size of at least 60 patients presented higher methodological quality (p = 0.025). Upon multiple regression, reporting on preoperative care and the experience level of surgeons were independent factors of quality.

Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis.

PURPOSE: Laparoscopic repair of large hiatal hernias is associated with high recurrence rates. Erosion and mesh migration are rare but devastating complications of synthetic mesh repair, whereas reoperation is accompanied by significant operative morbidity. The aim of this study was to estimate the comparative risk of hernia recurrence following primary suture or biologic mesh repair. METHODS: A systematic literature search of the MEDLINE database was performed and comparative data of relevant studies were combined using the Mantel-Haenszel meta-analysis model. The odds ratio (OR) for hernia recurrence with 95 % confidence interval (CI) was calculated. RESULTS: Five relevant studies (two randomized controlled trials and three case-control studies) and one follow-up report of a randomized trial, encompassing 295 patients, were identified. Small intestine submucosa and human acellular cadaveric dermis were used as mesh grafts. Short-term recurrence rates were 16.6 and 3.5 % for suture repair and biologic mesh repair, respectively (OR 3.74, 95 % CI 1.55-8.98, p = 0.003). Long-term recurrence based on data provided by one trial only was 51.3 and 42.4 %, respectively (OR 1.43, 95 % CI 0.56-3.63, p = 0.45). Sensitivity analysis of the two randomized trials at short-term follow up demonstrated no significant difference (OR 2.54, 95 % CI 0.92-7.02, p = 0.07). CONCLUSIONS: Biologic mesh repair of large hiatal hernias may confer short-term benefits in terms of hernia recurrence; however, the limited available information does not allow us to make conclusions about the long-term efficacy of biologic mesh in this setting. Individual biologic mesh grafts require further clinical assessment.

EAES recommendations for the management of gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS: The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS: Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS: Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Current treatment concepts for groin hernia.

PURPOSE: The purpose of this study is to review the latest evidence on operative and perioperative management of patients with groin hernia. METHODS: A literature review of medical databases was undertaken. Recent scientific evidence provided by quality reports was selected and discussed critically. RESULTS: The Shouldice repair results in low recurrence rates compared to other tissue reconstructions. However, mesh repairs are superior to tissue reconstruction in terms of recurrence. Lichtenstein's technique remains the gold standard, with low incidence of hernia recurrence and minimal morbidity. Endoscopic techniques have been popularized during the past decades, as alternative approaches to open surgery. Both transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) are effective in the treatment of groin hernia, although the steep learning curve precludes popularization and may account for increased perioperative morbidity. CONCLUSIONS: Groin hernia surgery remains an evolving field of investigation. Mesh application remains the mainstay of durable results. Individual patient factors and hernia characteristics need to be taken into account when considering the most appropriate surgical practice.

Different effects of bariatric surgery on epigenetic plasticity in skeletal muscle of individuals with and without type 2 diabetes.

AIM: Bariatric surgery is highly effective for the treatment of obesity in individuals without (OB1) and in those with type 2 diabetes (T2D2). However, whether bariatric surgery triggers similar or distinct molecular changes in OB and T2D remains unknown. Given that individuals with type 2 diabetes often exhibit more severe metabolic deterioration, we hypothesized that bariatric surgery induces distinct molecular adaptations in skeletal muscle, the major site of glucose uptake, of OB and T2D after surgery-induced weight loss. METHODS: All participants (OB, n = 13; T2D, n = 13) underwent detailed anthropometry before and one year after the surgery. Skeletal muscle biopsies were isolated at both time points and subjected to transcriptome and methylome analyses using a comprehensive bioinformatic pipeline. RESULTS: Before surgery, T2D had higher fasting glucose and insulin levels but lower whole-body insulin sensitivity, only glycemia remained higher in T2D than in OB after surgery. Surgery-mediated weight loss affected different subsets of genes with 2,013 differentially expressed in OB and 959 in T2D. In OB differentially expressed genes were involved in insulin, PPAR signaling and oxidative phosphorylation pathways, whereas ribosome and splicesome in T2D. LASSO regression analysis revealed distinct candidate genes correlated with improvement of phenotypic traits in OB and T2D. Compared to OB, DNA methylation was less affected in T2D in response to bariatric surgery. This may be due to increased global hydroxymethylation accompanied by decreased expression of one of the type 2 diabetes risk gene, TET2, encoding a demethylation enzyme in T2D. CONCLUSION: OB and T2D exhibit differential skeletal muscle transcriptome responses to bariatric surgery, presumably resulting from perturbed epigenetic flexibility.

Blunt versus bladed trocars in laparoscopic surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Trocar-associated visceral injuries are rare but potentially fatal complications of laparoscopic access. More commonly, abdominal wall bleeding occurs, which usually requires hemostatic measures and prolongs operative time. Blunt-tipped trocars have been postulated to carry a lower risk of abdominal wall bleeding and intra-abdominal injuries. The aim of the present systematic review and meta-analysis was to comparatively evaluate the relative risks of abdominal wall bleeding, visceral injuries, and overall complications with the use of bladed and blunt-tipped laparoscopic trocars. METHODS: The databases of Medline, EMBASE, and the Cochrane Central Register of Randomized Trials were searched to identify randomized studies that compared trocar-associated complications with the use of blunt and bladed trocars. Primary outcome measure was the relative risk of abdominal wall trocar site bleeding, and secondary outcome measures included visceral injuries and overall complications. Outcome data were pooled and combined overall effect sizes were calculated using the fixed- or random-effects model. RESULTS: Eight eligible randomized trials were identified; they included 720 patients with a median Jadad score of 4. The incidence of abdominal wall bleeding for the blunt and the bladed trocar group was 3 and 9 %, respectively [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.21-0.88]. Trocar-associated morbidity rate, excluding bleeding events of the abdominal wall, was documented at 0.2 and 0.7 % of the blunt and the bladed trocar arm, respectively (OR 0.43, 95 % CI 0.06-2.97). The overall trocar-associated morbidity rate was 3 % in the blunt trocar group and 10 % in the bladed trocar group (OR 0.38, 95 % CI 0.19-0.77). CONCLUSIONS: Reliable data support a lower relative risk of trocar site bleeding and overall complications with blunt laparoscopic cannulas than bladed trocars. Transition to blunt trocars for secondary cannulation of the abdominal wall is thus strongly recommended. Larger patient populations are required to estimate the relative risk of visceral injuries.

Meta-analysis of laparoscopic versus open repair of perforated peptic ulcer.

BACKGROUND AND OBJECTIVES: Laparoscopic treatment of perforated peptic ulcer (PPU) has been introduced as an alternative procedure to open surgery. It has been postulated that the minimally invasive approach involves less operative stress and results in decreased morbidity and mortality. METHODS: We conducted a meta-analysis of randomized trials to test this hypothesis. Medline, EMBASE, and the Cochrane Central Register of Randomized Trials databases were searched, with no date or language restrictions. RESULTS: Our literature search identified 4 randomized trials, with a cumulative number of 289 patients, that compared the laparoscopic approach with open sutured repair of perforated ulcer. Analysis of outcomes did not favor either approach in terms of morbidity, mortality, and reoperation rate, although odds ratios seemed to consistently support the laparoscopic approach. Results did not determine the comparative efficiency and safety of laparoscopic or open approach for PPU. CONCLUSION: In view of an increased interest in the laparoscopic approach, further randomized trials are considered essential to determine the relative effectiveness of laparoscopic and open repair of PPU.

Robot-assisted laparoscopic surgery of the colon and rectum.

INTRODUCTION: Laparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery. METHODS: A systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection. RESULTS: Thirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean). CONCLUSIONS: Robotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.

Laparoscopic Nissen versus Toupet fundoplication: objective and subjective results of a prospective randomized trial.

BACKGROUND: Although symptom outcomes following laparoscopic fundoplication have been adequately evaluated in the past, comparative subjective data of laparoscopic Nissen and Toupet fundoplications are scarce. Multichannel intraluminal impedance monitoring (MII) has not been used so far for comparison of objective data. METHODS: One hundred patients with documented chronic gastroesophageal reflux disease (GERD) were randomly allocated to either floppy Nissen fundoplication (group I, n = 50) or Toupet fundoplication (group II, n = 50). Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 3 months after surgery. Subjective and objective outcome data were compared to those of healthy individuals. RESULTS: Symptom intensity was significantly more severe and GIQLI showed impairment in the examined patient population compared to healthy controls. Both procedures resulted in a significant improvement in GIQLI and GERD symptoms (p < 0.01). Dysphagia improved significantly only in group II, while cough, asthma, and distortion of taste improved significantly in both groups. Hoarseness symptoms showed some degree of improvement in both groups but reached statistical significance only in group I. Postoperatively, bowel symptoms partly increased and the ability to belch decreased in both groups (p < 0.05). Comparison of postoperative GIQLI and symptom scores showed no significant difference between the two groups, except for the ability to belch, which was more impaired after Nissen fundoplication. Both procedures resulted in a significant improvement in lower esophageal sphincter (LES) pressure; however, the improvement was greater in group I than in group II. MII data showed more reflux control after Nissen, but the differences between the procedures were not significant. CONCLUSIONS: Both procedures equally improve quality of life and GERD symptoms. Bowel symptoms may increase after both procedures at the 3-month follow-up. Manometry and MII data favor Nissen fundoplication, but dysphagia and the inability to belch are more common compared to Toupet fundoplication.

A comprehensive review of telementoring applications in laparoscopic general surgery.

BACKGROUND: Incorporation of advanced laparoscopic procedures in the practice of institutions without respective experience is a significant impediment in the dissemination of minimally invasive techniques. On-site mentoring programs carry several cost-related and practical constraints. Telementoring has emerged as a practical and cost-effective alternative mentoring tool. The present study aimed to review the pertinent literature on telementoring applications in laparoscopic general surgery. METHODS: A systematic review using the Medline database was performed. Articles reporting on clinical experience with telementoring applications in general surgery were included. Variations in methodology, study design, and operative procedures precluded cumulative outcome evaluation. Instead, a critical appraisal of current evidence was undertaken. RESULTS: Seventy-five articles were identified in the primary search, and ten studies were considered eligible. No randomized studies comparing on-site mentoring with telementoring were identified. The included studies reported on a total of 96 laparoscopic telementored procedures: 50 cholecystectomies, 23 colorectal resections, 7 fundoplications, 9 adrenalectomies, 6 hernia repairs, and 2 splenectomies. Completion of remotely assisted procedures was feasible in the vast majority of cases, whereas technical difficulties included video and audio latency with low transfer rates (<128 kbps) and inadequate guidance regarding the correct plane for dissection. CONCLUSION: Current evidence supports the feasibility and safety of telementoring programs in general surgery. Their clinical effectiveness as teaching alternatives to traditional mentoring programs remains to be further evaluated.

Endoscopic full-thickness plication versus laparoscopic fundoplication: a prospective study on quality of life and symptom control.

BACKGROUND: Endoscopic antireflux techniques have emerged as alternative therapies for gastroesophageal reflux disease (GERD). Endoscopic plication receives continuing interest as an effective and safe procedure. This treatment option has not been the subject of comparison with well-established operative therapies to date. The present study aimed at comparatively evaluating the effectiveness of endoscopic plication and laparoscopic fundoplication in terms of quality of life and symptom control. METHODS: Between October 2006 and April 2010, 60 patients with documented GERD were randomly assigned to undergo either endoscopic plication or laparoscopic fundoplication. Quality-of-life scores and symptom grading were recorded before treatment and at 3- and 12-month follow-up. Outcomes were compared with the statistical significance set at a p value of 0.05. RESULTS: Twenty-nine patients from the endoscopic group and 27 patients from the operative group were available at follow-up. Quality-of-life scores showed a substantial and similar increase for both groups after treatment. Symptoms of heartburn (p < 0.02), regurgitation (p < 0.004), and asthma (p = 0.03) were significantly improved in the endoscopic group, whereas laparoscopic fundoplication was more effective in controlling symptoms of heartburn (p < 0.01) and regurgitation (p < 0.05) compared to the endoscopic procedure. CONCLUSIONS: Endoscopic plication and laparoscopic fundoplication resulted in significant symptom improvement with similar quality-of-life scores in a selected patient population with GERD, whereas operative treatment was more effective in the relief of heartburn and regurgitation at the expense of higher short-term dysphagia rates.

Mesh-reinforced hiatal hernia repair: a review on the effect on postoperative dysphagia and recurrence.

PURPOSE: The objective of the present study was to review the pertinent literature and analyze the evidence for and against the use of mesh for hiatal hernia repair, with a focus on the effects on recurrence and postoperative dysphagia. METHODS: A literature search was performed between January 1990 and March 2010. Studies were considered for inclusion, provided (1) they comprised a series of at least 20 patients, (2) they documented a follow-up period of at least 6 months, (3) they reported on the outcome as expressed by hernia recurrence rates, and (4) they reported on type of mesh material, hiatal closure, and antireflux surgery. RESULTS: Twenty-three articles enrolling a cumulative number of 1,446 patients fulfilled the inclusion criteria. Polypropylene meshes seem to be associated with low recurrence rates (0-22.7%, median 1.9%) and acceptable dysphagia rates (0-21.7%, median 3.9%). Higher dysphagia rates after polytetrafluoroethylene (PTFE) and expanded PTFE (ePTFE) mesh hiatoplasty have been recorded (15.5-34.3%). Even though the use of novel biologic implants for hiatal repair is still in its infancy, the existing results from clinical research are promising. CONCLUSIONS: Polypropylene meshes seem to provide durable results with low dysphagia rates. Unacceptably high recurrence rates for PTFE/ePTFE meshes have been reported. Biologic implant engineering represents a promising field in hiatal hernia surgery.

Abdominal aortic aneurysm and abdominal wall hernia as manifestations of a connective tissue disorder.

BACKGROUND: Abdominal aortic aneurysms (AAAs) and abdominal wall hernias represent chronic degenerative conditions. Both aortic aneurysms and inguinal hernias share common epidemiologic features, and several investigators have found an increased propensity for hernia development in patients treated for aortic aneurysms. Chronic inflammation and dysregulation in connective tissue metabolism constitute underlying biological processes, whereas genetic influences appear to be independently associated with both disease states. A literature review was conducted to identify all published evidence correlating aneurysms and hernias to a common pathology. METHODS: PubMed/Medline was searched for studies investigating the clinical, biochemical, and genetic associations of AAAs and abdominal wall hernias. The literature was searched using the MeSH terms "aortic aneurysm, abdominal," "hernia, inguinal," "hernia, ventral," "collagen," "connective tissue," "matrix metalloproteinases," and "genetics" in all possible combinations. An evaluation, analysis, and critical overview of current clinical data and pathogenic mechanisms suggesting an association between aneurysms and hernias were undertaken. RESULTS: Ample evidence lending support to the clinical correlation between AAAs and abdominal wall hernias exists. Pooled analysis demonstrated that patients undergoing aortic aneurysm repair through a midline abdominal incision have a 2.9-fold increased risk of developing a postoperative incisional hernia compared with patients treated for aortoiliac occlusive disease (odds ratio, 2.86; 95% confidence interval, 1.97-4.16; P < .00001), whereas the risk of inguinal hernia was 2.3 (odds ratio, 2.30; 95% confidence interval, 1.52-3.48; P < .0001). Emerging evidence has identified inguinal hernia as an independent risk factor for aneurysm development. Although mechanisms of extracellular matrix remodeling and the imbalance between connective tissue degrading enzymes and their inhibitors instigating inflammatory responses have separately been described for both disease states, comparative studies investigating these biological processes in aneurysm and hernia populations are scarce. A genetic predisposition has been documented in familial and observational segregation studies; however, the pertinent literature lacks sufficient supporting evidence for a common genetic basis for aneurysm and hernia. CONCLUSIONS: Insufficient data are currently available to support a systemic connective tissue defect affecting the structural integrity of the aortic and abdominal wall. Future investigations may elucidate obscure aspects of aneurysm and hernia pathophysiology and create novel targets for pharmaceutical and gene strategies for disease prevention and treatment.

Single-incision laparoscopic cholecystectomy: a systematic review.

BACKGROUND: Laparoscopic techniques induced a tremendous revolution in surgery of the biliary tract, mainly due to improved results compared with the open approach and secondary because of their cosmetic advantage. A trend toward even more minimally invasive approaches has led to techniques of single-incision and natural orifice laparoscopic surgery. Because the evaluation of single-incision laparoscopic cholecystectomy (SILC) is rather fragmentary by single-institution small patient series, this article intends to examine the success and the risks of the technique, and attempts to determine its potential limitations. METHODS: A systematic review of the literature was performed to identify relevant articles. Studies enrolling at least ten patients who underwent SILC and reporting on analytical complication data were considered for inclusion. RESULTS: The literature search identified 29 studies, which included a total of 1,166 patients. Success and complication rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2 min and mean adjusted hospital stay was 1.4 days. Analysis of outcome exhibited higher complication rates for studies with a mean patient age older than 45 years (p=0.04), and higher operative time for studies with a mean body mass index>30 kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min). Acute cholecystitis as inclusion criterion was a factor for technical failure (success rate 59.9 vs. 93.0%, p=0.005) and resulted in an increase of operative time (78.1 vs. 70.6 min). Suture suspension of the gallbladder yielded significantly lower complication rates compared with instrument usage (3.3 vs. 13.3%, p<0.0001). CONCLUSIONS: The clinical application of SILC exhibited satisfactory results. Cases of acute cholecystitis and older patients should be approached with caution, whereas improvement of the instrumentation is necessary.