Robotic versus laparoscopic approach to treat symptomatic achalasia: systematic review with meta-analysis.

Minimally invasive Heller myotomy is considered the gold standard surgical approach for symptomatic achalasia because it is a safe and effective procedure. Over the last years, several studies comparing the laparoscopic and robotic approach for Heller myotomy have been published. Although the robotic approach appears to have some advantages over standard laparoscopy, data on this topic are still controversial and no definite conclusions have been drawn. This metanalysis has been designed to systematically evaluate and compare the effectiveness and safety of the robot-assisted Heller myotomy as compared to the standard laparoscopic approach. According to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic search on both laparoscopic and robotic Heller myotomy was performed in all the major electronic databases (PubMed, Web of Science, Scopus, EMBASE), using the following search string: (achalasia OR Dor) AND robotic. Six articles were included in the final analysis. A metaregression analysis was performed to assess the possible effects of demographic variables (age, gender, body mass indes (BMI)) and previous abdominal surgery or endoscopic intervention on the analyzed outcomes. No statistical difference was observed in operative times (mean difference (MD) = 20.79, P = 0.19, 95% confidence interval (CI) -10.05,51,62), estimated blood loss (MD = -17.10, P = 0.13, 95% CI -40.48,5.08), conversion rate to open surgery (risk difference (RD) = -0.01, P = 0.33, 95% CI -0.05,0.02), length of hospital stay (MD = -0.73, P = 0.15, 95% CI -1.71,0.25) and long-term recurrence (odds ratio (OR) = 0.59, P = 0.45, 95% CI 0.15,2.33). On the contrary, the robotic approach was found to be associated with a significantly significant lower rate of intraoperative esophageal perforations (OR = 0.13, P < 0.001, 95% CI 0.04, 0.45). Our results suggest that the robotic approach is safer than the laparoscopic Heller myotomy, encouraging the use of robot-assisted surgery. However, our analysis is limited because of the exiguous number of comparative studies and because most of the included studies were statistically underpowered, given the small sample size. Moreover, a high degree of heterogeneity was observed in most of published studies. Taking in consideration the additional costs of robot-assisted procedures, larger Randomized Controlled Trials (RCTs) are advocated to confirm the safety and effectiveness of the robotic approach, and its advantages over standard laparoscopic surgery. In conclusion, well-designed prospective trials and RCTs with homogeneous parameters are needed to draw definitive conclusions about the best surgical approach to pursue in treating symptomatic achalasia.

Sterile carbon particle suspension vs India ink for endoscopic tattooing of colonic lesions: a randomized controlled trial.

BACKGROUND: Different markers have been used preoperatively to mark colonic lesions, especially India ink. In recent years, another kind of marker has been developed: sterile carbon particle suspension (SCPS). No comparison between these two markers has yet been made. The aim of the present study was to compare the pyrogenic, inflammatory and intraperitoneal effect of these two markers. METHODS: From September 2015 to December 2018, adult patients who were candidates for elective laparoscopic colon resection were randomized to the SCPS or conventional India ink injection group using computer-based randomization. The primary endpoint of the study was the presence of intraoperative adhesions related to the endoscopic tattoo. Secondary endpoints were differences in white blood cell, C-reactive protein, and fibrinogen levels as well as, abdominal pain and body temperature at baseline (before endoscopic tattooing) and 6 and 24 h after colonoscopy. Finally, the visibility of the tattoo during the minimally invasive intervention was assessed. RESULTS: Ninety-four patients were included in the study, 47 for each arm. There were 45/94 females (47.9%) and 49/94 males (52.1%), with a median age of 67.85 ± 9.22 years. No differences were found between groups in WBC, fibrinogen levels, body temperature or VAS scores, but we documented significantly higher CRP values at 6 and 24 h after endoscopic tattooing with India ink injection. There were significantly fewer adhesions in the SCPS Endoscopic Marker group. All the endoscopic tattoos were clearly visible. CONCLUSIONS: SCPS is an effective method for tattooing colonic lesions and has a better safety profile than traditional India ink in terms of post-procedure inflammatory response and intraoperative bowel adhesions. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (ID: NCT03637933).

Confocal laser endomicroscopy in ulcerative colitis: beyond endoscopic assessment of disease activity.

BACKGROUND: The aim of this study was to investigate the role of confocal laser endomicroscopy (CLE) in the assessment of disease activity in ulcerative colitis (UC). METHODS: Consecutive patients with UC referred to our inflammatory bowel disease unit for colonoscopy were enrolled. Patients without UC were used as controls. UC activity was evaluated by white light endoscopy and classified according to the Mayo Ulcerative Colitis Endoscopic Score of Severity. Endoscopic biopsies were also taken for histological assessment of disease activity and then assessed with CLE. Three parameters were evaluated; crypt architecture (crypt diameter, inter-crypt distance, presence of fused crypts, crypts regularity), microvascular pattern (regular, dilated, irregular and deformed), fluorescein leakage. RESULTS: Fifty patients with UC and 10 controls were enrolled. At colonoscopy, 11 patients (22%), 19 patients (38%), 12 patients (24%) and 8 patients (16%) presented a Mayo score of 0, 1, 2 and 3, respectively. At CLE, fused crypts were present in all the patients with UC and absent in controls. Crypt diameter and inter-crypt distance showed a parallel increase with the Mayo score. Fluorescein leakage and irregular vessels were more frequently found in case of a high level of endoscopic severity, but were also identified in about 20% of UC patients with normal mucosa. Biopsies also demonstrated the presence of histological activity in 4 patients with endoscopically inactive colitis. CONCLUSIONS: CLE might be a useful tool to determine inflammatory activity in UC. Fused crypts appeared to be a CLE marker of UC, while other abnormalities, like microvascular alteration and fluorescein leakage, have also been identified in patients with mucosal healing at endoscopy. Larger series are required to validate these results and the advantages of a CLE-based assessment of UC activity.

In vivo assessment of tumour angiogenesis in colorectal cancer: the role of confocal laser endomicroscopy.

AIM: Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study was to establish the role of probe-based confocal laser endomicroscopy (p-CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy. METHOD: Fourteen consecutive patients with colorectal cancer were included. The following features were identified and then compared between normal and neoplastic mucosa on p-CLE images: vessel shape (straight vs irregular) vessel diameter the 'branching patterns' vessel permeability (fluorescein leakage) and blood flow (normal vs defective flux). Immunohistochemistry was used to confirm the presence and to study the morphology of vascular structures (CD-34 staining) and 'neo-vessels' (WT-1 staining) on tumour and normal mucosal sections. RESULTS: Tumour vessels appeared as irregular, ectatic and with a highly variable calibre and branching patterns on p-CLE images. The mean diameter of tumour vessels was significantly larger than those in normal mucosa (weighted mean difference 3.38, 95% CI 2.65-4.11, P = 0.01). Similarly, 'vessel branching' (OR 2.74, 95% CI 1.23-6.14, P = 0.01), fluorescent dye 'extravasation' (OR 3.46, 95% CI 1.39-8.57, P = 0.01) were significantly more frequent in colorectal cancer than in normal colorectal mucosa. Immunohistochemistry corroborated the p-CLE findings, showing higher vascularity in tumour sections due to neoformed vessels, presenting irregular patterns. CONCLUSION: Probe-based confocal laser endomicroscopy provides a noninvasive characterization of the microvascular architecture of colonic mucosa. Different morphological patterns have been described, discriminating normal and malignant microvascular networks in colorectal mucosa.

Intracorporeal versus extracorporeal anastomosis after laparoscopic gastrectomy for gastric cancer. A systematic review with meta-analysis.

AIM: To perform a systematic review and meta-analyses of studies comparing the totally laparoscopic procedures with intracorporeal anastomosis (IA) to laparoscopic-assisted surgery with extracorporeal anastomosis (EA) in gastric resections. METHODS: We performed a systematic search in the electronic databases. Outcomes analysed were: intraoperative (operative time and intraoperative blood loss), oncologic (harvested nodes, distance of the tumour from proximal and distal margin), postoperative complications (gastric stasis, intraluminal and extraluminal bleeding, leakage and wound infection) recovery (time to first flatus, time to first oral intake and hospital stay). We performed meta-regression analyses after implementing a regression model with the analysed outcomes as dependent variables (y) and the demographic and pathologic covariates as independent variables (x). RESULTS: A total of 26 studies (20 on distal gastrectomy and 6 on total gastrectomy) were included in the final analysis. Regarding distal gastrectomy, there was no statistical difference between the two groups in the above-mentioned outcomes, except for intraoperative blood loss (less in IA group, P=0.003), number of harvested nodes (better in the IA group, P=0.022) and length of hospital stay (shorter in the IA group, P=0.037). Regarding total gastrectomy, there was no statistical difference for all outcomes, except for the distal margin (further in the EA group, P=0.040). Meta-regression analysis showed that a lot of variables influenced results in distal gastric resections, but not in total gastric resections. CONCLUSION: We can state laparoscopic gastric resections with IA are safe and feasible when performed by expert surgeons. However, new well-designed studies comparing the two techniques are needed to confirm the benefits of laparoscopic IA.