Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy.

BACKGROUND: The role of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery is still debatable. The aim of this meta-analysis was to evaluate the potential improvement of IONM versus RLN visualization alone (VA) in reducing the incidence of vocal cord palsy. METHODS: A literature search for studies comparing IONM versus VA during thyroidectomy was performed. Studies were reviewed for primary outcome measures: overall, transient, and permanent RLN palsy per nerve and per patients at risk; and for secondary outcome measures: operative time; overall, transient and permanent RLN palsy per nerve at low and high risk; and the results regarding assistance in RLN identification before visualization. RESULTS: Twenty studies comparing thyroidectomy with and without IONM were reviewed: three prospective, randomized trials, seven prospective trials, and ten retrospective, observational studies. Overall, 23,512 patients were included, with thyroidectomy performed using IONM compared with thyroidectomy by VA. The total number of nerves at risk was 35,513, with 24,038 nerves (67.7%) in the IONM group, compared with 11,475 nerves (32.3%) in the VA group. The rates of overall RLN palsy per nerve at risk were 3.47% in the IONM group and 3.67% in the VA group. The rates of transient RLN palsy per nerve at risk were 2.62% in the IONM group and 2.72% in the VA group. The rates of permanent RLN palsy per nerve at risk were 0.79% in the IONM group and 0.92% and in the VA group. None of these differences were statistically significant, and no other differences were found. CONCLUSIONS: The current review with meta-analysis showed no statistically significant difference in the incidence of RLN palsy when using IONM versus VA during thyroidectomy. However, these results must be approached with caution, as they were mainly based on data coming from non-randomized observational studies. Further studies including high-quality multicenter, prospective, randomized trials based on strict criteria of standardization and subsequent clustered meta-analysis are required to verify the outcomes of interest.

Meta-analysis of studies comparing single-incision laparoscopic appendectomy and conventional multiport laparoscopic appendectomy.

BACKGROUND: There is no consensus that single-incision laparoscopic appendectomy (SILS-A) is on a par with conventional multiport laparoscopic appendectomy (CMLA). The aim of this meta-analysis was to assess feasibility, safety, and potential benefits of SILS-A when compared with CMLA. METHODS: A literature search for studies comparing SILS-A and CMLA was performed. Studies were reviewed for the outcome of interest: patient characteristics, operative outcome, postoperative recovery, postoperative morbidity, patient satisfaction, and cosmetic results. RESULTS: Thirteen studies comparing SILS-A and CMLA were reviewed: two prospective randomized trials, four prospective studies, and seven retrospective studies. Overall, 893 patients were operated on: by SILS-A in 402 cases (45.0%) versus 491 cases (55.0%) by CMLA. Patients in the SILS-A group were significantly younger than those in the CMLA group (31.2 versus 33.5 y). No other differences were found. Patient satisfaction score was impossible to meta-analyze. CONCLUSIONS: Appendectomy via SILS-A may be considered as an alternative to CMLA. However, these results must be approached with caution as they are based on data from nonrandomized observational studies. The feasibility and safety of SILS-A must be mainly assessed for difficult clinical situations such as severe obesity, localized abscess, or diffuse peritonitis from a ruptured appendix in the setting of new prospective randomized trials.

Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT).

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance among surgeons as its feasibility has been well documented. The aim of this systematic review with meta-analysis has been to assess and validate the safety and feasibility of MIVAT when compared to conventional thyroidectomy (CT) and to verify other potential benefits and drawbacks. METHODS: A literature search for prospective randomized trials comparing MIVAT and CT was performed. Trials were reviewed for the primary outcome measures: overall morbidity, recurrent laryngeal nerve palsy, postoperative hypocalcemia, and postoperative hematoma; and for the secondary outcome measures: operative time, conversion to standard procedure, intraoperative blood loss, intraoperative drain insertion, nodule size and thyroid weight, postoperative pain evaluation, length of hospital stay, patient satisfactory score, and cosmetics results. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables. RESULTS: Nine prospective randomized studies comparing MIVAT and CT were analyzed. Overall, 581 patients were randomized to either MIVAT (289, 49.7 %) or CT (292, 50.3 %). The primary outcome measures of MIVAT were comparable with those of CT without statistically significant difference. Patients who underwent MIVAT experienced significantly less pain than those operated on conventionally during the whole postoperative period. Patient satisfactory score significantly favored MIVAT (9.0 vs. 6.8, SMD = -3.388, 95 % CI = -5.720 to -1.057). Operative time was significantly longer in MIVAT (75.2 vs. 59.2 min, SMD = 1.246, 95 % CI = 0.227-2.266). CONCLUSIONS: MIVAT is a safe and feasible alternative for the removal of small-volume benign thyroid disease and low-risk papillary thyroid carcinomas showing better cosmetics results and less postoperative pain but significantly longer operative time when compared to CT. New multicenter randomized studies are needed to evaluate the technique in more complex circumstances such as intermediate-risk thyroid cancer, lymph node removal, thyroiditis, and Graves' disease.

Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC).

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) has gained acceptance among surgeons as there is a trend to minimize the invasiveness of laparoscopy. The aim of this meta-analysis has been to assess the feasibility and safety of SILC when compared to conventional multiport laparoscopic cholecystectomy (CMLC). METHODS: A literature search for trials comparing SILC and CMLC was performed. Studies were reviewed for the outcomes of interest: patient characteristics; operative time and conversion rate; postoperative pain; length of hospital stay; postoperative complications; and patient satisfactory score (0-10). Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables. RESULTS: Twelve prospective randomized trials comparing SILC and CMLC were analyzed. Overall, 892 patients were randomized to either SILC (465) or CMLC (427). Operative time was significantly longer in SILC (63.0 vs. 45.8 min, SMD = 1.004, 95% CI = 0.434-1.573). Patient satisfactory score significantly favored SILC (8.2 vs. 7.2, SMD = -0.759, 95% CI = -1.064 to -0.455). No other difference was found. CONCLUSIONS: SILC is a safe and effective procedure for the treatment of uncomplicated benign gallbladder disease with a significant patient satisfaction. New multicenter randomized trials are expected to evaluate SILC in more complex circumstances such as acute cholecystitis, previous abdominal surgery, and severe obesity.