Platelet rich plasma for the management of urogynecological disorders: the current evidence.

PURPOSE OF REVIEW: Our objective is to review the currently available literature on the use of platelet-rich plasma (PRP) in patients with pelvic floor disorders and to critically appraise the latest evidence on the safety and efficacy of the PRP application. RECENT FINDINGS: The evidence on the use of PRP for the treatment of stress urinary incontinence (SUI) appears promising, although limited to case series, case reports and animal studies. PRP has also been proposed to enhance the surgical outcomes of pelvic organ prolapse (POP) by native tissue repair with promising success rates. The application of PRP in other PFDs including vaginal fistulas, genitourinary syndrome of menopause (GSM), mesh exposure and lichen sclerosus has been also associated with beneficial outcomes and a favorable safety profile. SUMMARY: The currently available literature indicates that PRP could have a beneficial effect as a single or adjuvant treatment in patients with SUI, POP, GSM, vaginal fistula and genital lichen sclerosus with minimal adverse events. However, valid evidence is still lacking and further well-designed studies are warranted in the field to confirm the validity of the so far reported outcomes.

The Emerging Role on the Use of Platelet-Rich Plasma Products in the Management of Urogynaecological Disorders.

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

GNRI as a Prognostic Factor for Outcomes in Cancer Patients: A Systematic Review of the Literature.

Oncologic patients often suffer from malnutrition which in turn, might have negative impact on treatment outcomes. The Geriatric Nutritional Risk Index (GNRI), as an index of impaired nutritional status, has emerged as a significant prognostic factor for short-and long-term outcomes in cancer patients. The aim of the current systematic review is to determine whether the GNRI is an independent prognostic factor of postoperative complications and survival in cancer patients. A systematic search was conducted to identify studies, published from 2005 to 2019, which assessed associations between GNRI and short- and long-term outcomes in cancer patients. Eighteen studies fulfilled the eligibility criteria and were included in the analysis. Low scores of GNRI were associated with increased risk for developing postoperative complications and impaired survival of cancer patients in most studies. Our findings support the use of the GNRI in the clinical practice, since it is a simple and reliable tool for assessing nutritional status in oncologic patients. More prospective, multi-centered studies are warranted to confirm the current results, as well as the role of nutritional support in improving the prognosis of cancer patients.

Pelvic floor reconstructive surgery under local anesthesia: A systematic review and meta-analysis.

AIMS: The decision on the appropriate type of anesthesia for pelvic floor repair depends on a variety of factors including patients' age, performance status, comorbidities, cost-effectiveness and personal preferences. We aim to review the literature on urogynecological procedures performed under local anesthesia (LA). METHODS: A systematic search of four electronic databases was conducted for articles published up to May 2020. Studies reporting outcomes of women who underwent pelvic floor reconstructive surgery under LA with or without sedation, were considered eligible. RESULTS: Nineteen studies (14 noncomparative and 5 comparative), including 1626 cases of urogynecological procedures under LA were recruited. Meta-analysis revealed significantly lower mean pain scores in LA group compared to general-regional anesthesia one (GA/RA) at both 4-6 h and 8-18 h postoperatively (160 patients; mean difference [MD], -1.70; 95% confidence interval [CI]: -3.12, -0.28; p = 0.02 and 160 patients; MD, -0.72; 95% CI: -1.17, 0.27; p = 0.002, respectively). Pain scores at >24 h did not differ among the two groups (160 patients; MD, -0.28; 95% CI: -0.60-0.05; p = 0.10). Intra- and postoperatively morphine use was not different among patients who received LA and GA during prolapse surgery while nausea rates were significantly lower in LA group compared to RA group 8 h postoperatively. CONCLUSIONS: LA with or without sedation represents a safe and efficient alternative anesthetic technique for urogynecological procedures with improved pain scores in up to 18 h postoperatively especially in patients who underwent surgery for SUI. LA is feasible and could be offered to patients undergoing pelvic floor surgery allowing a prompt postoperative recovery.

The Emerging Role of Robotic Single-site Approach for Myomectomy: A Systematic Review of the Literature.

Objective. To review the existing studies on single-site robotic myomectomy and test the safety and feasibility of this innovative minimally invasive technique. Data Sources. PubMed, Scopus, Google Scholar (from their inception to October 2019), as well as Clinicaltrials.gov databases up to April 2020. Methods of Study Selection. Clinical trials (prospective or retrospective) that reported the outcomes of single-site robotic myomectomy, with a sample of at least 20 patients were considered eligible for the review. Results. The present review was performed in accordance with the guidelines for Systematic Reviews and Meta-Analyses (PRISMA). Four (4) studies met the inclusion criteria, and a total of 267 patients were included with a mean age from 37.1 to 39.1 years and BMI from 21.6 to 29.4 kg/m2. The mean operative time ranged from 131.4 to 154.2 min, the mean docking time from 5.1 to 5.45 min, and the mean blood loss from 57.9 to 182.62 ml. No intraoperative complications were observed, and a conversion rate of 3.8% was reported by a sole study. The overall postoperative complication rate was estimated at 2.2%, and the mean hospital stay ranged from 0.57 to 4.7 days. No significant differences were detected when single-site robotic myomectomy was compared to the multiport technique concerning operative time, blood loss, and total complication rate. Conclusion. Our findings support the safety of single-site robotic myomectomy and its equivalency with the multiport technique on the most studied outcomes. Further studies are needed to conclude on the optimal minimally invasive technique for myomectomy.

The role of inflammation biomarkers in differential diagnosis of pelvic tumours of ovarian origin: a single-centre observational study.

AIM OF THE STUDY: Our aim was to analyse the feasibility of white blood cell and platelet counts along with their ratios as a prognostic factor in patients who underwent surgery for ovarian mass. MATERIAL AND METHODS: We retrospectively studied the patients admitted in the Department of Gynaecology due to adnexal mass. The potential association of the neutrophil-to-lymphocyte-ratio (NLR), neutrophil-to-monocyte (NMR), platelet-to-lymphocyte (PLR), lymphocyte-to-monocyte (LMR), monocyte-to-platelet, and malignancy was evaluated. RESULTS: Patients with malignant tumours were found with significantly higher ratios of NLR (p < 0.001) and PLR (p < 0.001) and lower LMR ratio (p < 0.001) compared to those with benign tumours. Furthermore, higher lymphocyte count (p = 0.04) and platelet count (p = 0.004) were found in cancer patients when compared with borderline tumours. No significant variations were detected regarding white blood cell count (p = 0.238), NMR ratio (p = 0.28), platelet-to-neutrophil ratio (p = 0.12), and platelet-to-monocyte ratio (p = 0.34). CONCLUSIONS: Inflammation biomarker ratios can easily and inexpensive assist in distinguishing malignant ovarian tumours from benign ones.

Diagnosis, surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review.

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment. Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion. A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively. Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.

The Emerging Role of Neutral Argon Plasma (PlasmaJet) in the Treatment of Advanced Stage Ovarian Cancer: A Systematic Review.

Objective. To evaluate the contribution of PlasmaJet application in achieving optimal cytoreduction in advanced ovarian cancer. Methods. We systematically searched for articles published up to June 2019 using MEDLINE, Scopus, Google Scholar databases and clinicaltrials.gov along with the references of the articles retrieved in full text. Observational studies and case reports addressing cases of women with peritoneal spread due to advanced stage ovarian cancer who were treated with application of PlasmaJet device were considered eligible for inclusion. Results. Three studies were excluded from further analysis when they were retrieved in full text. Five studies (2 retrospective, 1 prospective, and 2 case reports) that comprised 77 patients with age range from 38 to 85 years were included. Forty-three women underwent interval debulking surgery, 24 patients primary debulking surgery, and 6 had optimal debulking surgery, while in the remaining 4, a secondary debulking surgery was performed. Incidence of intraoperative complications was 32% (8/25), but none of them was due to the application of PlasmaJet. Complete macroscopic resection was achieved in 59 out of 70 (84.3%) women. Postoperatively, 17 out of 72 patients (23.6%) developed complications such as pneumothorax due to diaphragmatic resection, systemic infections, or wound-related complications. No postoperative mortality was recorded. Conclusions. Preliminary data on the use of PlasmaJet for ablation of ovarian cancer implants in the peritoneal cavity showed its safety and presented with promising outcomes in achieving complete cytoreduction.

Systematic Review of Surgical and Percutaneous Irreversible Electroporation in the Treatment of Locally Advanced Pancreatic Cancer.

OBJECTIVE: The aim of the present systematic review was to collect, analyze, and critically evaluate the role of irreversible electroporation (IRE) in locally advanced pancreatic cancer (LAPC). Furthermore, we sought to analyze the different approaches of IRE (open, laparoscopic, and percutaneous) and assess the relative outcomes. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using the MEDLINE (1966-2018), Scopus (2004-2018), Google Scholar (2004-2018) and ClinicalTrials.gov databases, eligible articles published up to August 2018 were included. The following keywords were applied: 'irreversible electroporation', 'IRE', 'LAPC', 'unresectable pancreatic cancer', 'palliative treatment', 'locally advanced pancreatic cancer', 'ablation' and 'ablative treatment'. RESULTS: IRE for LAPC was feasible and safe; however, it was associated with morbidity in approximately one in three patients, some of whom experienced serious complications, particularly after surgical IRE. In addition, while mortality following IRE was uncommon, it did occur in 2% of patients. While some studies suggested a survival benefit, others failed to note an improvement in long-term outcomes following IRE compared with other therapies. CONCLUSIONS: Providers and patients need to be aware of the potential morbidity and mortality associated with IRE. In addition, based on the literature to date, the survival benefit of IRE for LAPC remains to be elucidated. Conclusive and definitive evidence to support a survival benefit of IRE does not currently exist. Future multicenter, randomized, prospective trials are needed to clarify the role of IRE in patients with LAPC.

The application of fibrin sealant for the prevention of lymphocele after lymphadenectomy in patients with gynecological malignancies: A systematic review and meta-analysis of randomized controlled trials.

PURPOSE: The aim of the present study was to evaluate the correlation between the use of fibrin-collagen sealants on lymph node dissection areas and formation of lymphocele after lymphadenectomy in patients with gynecological malignancies. MATERIALS AND METHODS: A systematic search of 5 electronic databases for articles published up to November 2018 was performed. All randomized controlled clinical trials (RCTs) which reported outcomes after application of fibrin collagen agents in patients who underwent lymphadenectomy for gynecological malignancies, were finally included in the present meta-analysis. Statistical meta-analysis was performed using the RevMan 5.3 software. RESULTS: A total of 6 RCTs which recruited 481 patients were included in the present study. Meta-analysis revealed significantly decreased total amount of drained fluid and of mean duration of drainage in fibrin sealant group when compared to control, (187 patients MD -86.40 ml 95% CI -100.2 to -72.60 p < 0.00001 and 113 patients MD -1.00 days 95% CI -1.13 to -0,87 p < 0.00001, respectively). No difference in overall incidence of lymphocele and in the incidence of symptomatic ones among the two groups was observed (592 cases OR 0.61 95% CI 0.36 to 1.05 p = 0.08, and 444 cases OR 0.59 95% CI 0.26 to 1.35 p = 0.22, respectively). CONCLUSIONS: The present meta-analysis supports the safety of the use of fibrin sealants in women undergoing pelvic and/or para-aortic lymphadenectomy due to gynecologic cancer but its benefit remains uncertain. It was found effective in reducing the duration and volume of drainage, but it was not associated with difference in the incidence of lymphocele. Further studies are required to confirm our conclusion and broaden our knowledge about its impact on other parameters.

Laparoscopic synchronous resection of colorectal cancer and liver metastases: A systematic review.

While colorectal and hepatic resections are commonly performed through a laparoscopic approach, the safety and feasibility of total laparoscopic synchronous resections (LSR) of colorectal liver metastasis (CRLM) have not been established. In this systematic review, short- and long-term outcomes were comparable for patients undergoing LSR and open synchronous resection. LSR was safe and feasible for patients with synchronous CRLM and should be considered in well-selected patients.

Healing after Resection of Colonic Endometriosis and Growth Factor-enriched Agents: An Experimental Rat Model.

STUDY OBJECTIVE: To examine the potential beneficial effect of platelet-rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion. DESIGN: A single-blind, randomized study (Canadian Task Force classification I). SETTING: A certified animal research facility. ANIMALS: Thirty female Sprague-Dawley rats. INTERVENTIONS: Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment; PRP (group 1, n = 10), fibrin sealant (group 2, n = 10), or no agent (group 3, n = 10) was applied after shaving of the endometriotic nodule (second surgery). MEASUREMENTS AND MAIN RESULTS: Colonic endometriosis was successfully induced in all subjects. Four days after the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in a significantly higher expression in both the PRP and fibrin sealant groups (p = .011 and p = .011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p = .033), whereas greater new blood vessel formation was observed in the fibrin sealant group compared with the control (p = .023). No histologic evidence of residual or recurrent disease was detected. CONCLUSION: Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting.

Short- and long term outcomes after abdominal radical trachelectomy versus radical hysterectomy for early stage cervical cancer: a systematic review of the literature and meta-analysis.

PURPOSE: Cervical cancer (CC) ranks 2nd for mortality among women of reproductive age in the United States. Abdominal radical trachelectomy (ART) is a fertility sparing approach that has been proposed in women with early stage CC who wish to preserve their fertility. The aim of the present meta-analysis was to evaluate the short- and long-term outcomes of RH vs ART for early stage CC. METHODS: A total of 5 electronic databases were searched for articles published up to December 2018. Prospective and retrospective trials reporting outcomes for women who underwent ART or RH for the management of early stages CC, were considered eligible for inclusion. Statistical meta-analysis was performed using the RevMan 5.3 software. RESULTS: A total of 5 studies which included 840 women who underwent ART or radical trachelectomy (RH) were included in the present meta-analysis. Among them, 324 underwent ART whereas the remaining 516 had RH. Despite the fact that ART was associated with significantly prolonged operative time compared to RH (840 patients MD 36.82 min, 95% CI 20.15-53.49, p < 0.001), neither 5-year OS nor 5-year DFS were different among the two groups (714 patients OR 1.39, 95% CI 0.53-3.62, p = 0.51 and 682 patients OR 1.08, 95% CI 0.52-2.25, p = 0.84, respectively). CONCLUSIONS: ART is a more complex and time consuming technique, but equally safe compared to RH in terms of oncological outcomes for selected women with early stage CC and allows for more CC survivors of childbearing age to preserve their fertility.

Photodynamic Therapy for Vulvar Lichen Sclerosus-A Systematic Review.

OBJECTIVE: Lichen sclerosus (LS) is a disease affecting mostly genital and perianal areas. Photodynamic therapy (PDT) has gained interest during the past years. The present study accumulates current evidence on the efficacy of PDT in the management of vulvar LS. METHODS: We used Medline (1966-2017), Scopus (2004-2017), ClinicalTrials.gov (2008-2017) and Cochrane Central Register of Controlled Trials CENTRAL (1999-2017) databases in our primary search along with the reference lists of electronically retrieved full-text papers. RESULTS: Eleven studies were finally included in our systematic review, which recruited 337 women. The existing evidence supports that PDT results in significant relief of symptoms related to LS, hence remains confusing in evaluating the progress in the clinical appearance of the lesion. No major adverse effects were reported during therapy and during the posttreatment period. Pathologic findings seem to be conflicting, as current data do not unanimously support a beneficial histological effect. CONCLUSIONS: According to the findings of our study, PDT seems to be promising in the treatment of patients with vulvar LS. Nonetheless, current knowledge is extremely limited, and further observational studies with large patient series are needed in the field to elucidate the efficacy of PDT.

Survival and nutritional factors on home parenteral nutrition (HPN): Our initial experience.

PURPOSE: Home parenteral nutrition (HPN) has been proposed as the treatment of choice in patients suffering from intestinal failure (IF) and has been claimed to improve survival and quality of life either in patients with benign disorders or even in those with malignancies. The purpose of the present analysis was to report characteristics and outcomes of adult patients with IF receiving HPN in Greece. METHODS: Patients that received HPN between 2011 and 2017 were included in this retrospective analysis. Characteristics of the included patients, cause of HPN, duration of HPN, route of HPN administration, complications as well as survival rates were recorded. RESULTS: A total of 189 patients were included in the present analysis. Of these, 163 (86.3%) suffered from cancer while 26 (13.7%) received HPN due to non-malignant diseases. The reported mortality was 74.6% while overall severe complications rate was 77%. CONCLUSIONS: According to the findings of our study, HPN seems to have beneficial effect but it should be considered with caution by the physicians who should take into account the indications of each patient to receive parenteral nutrition, the underlying disease and prognosis and the access of each patient to home care services.

The diagnostic efficacy of platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in ovarian cancer.

BACKGROUND: Platelet-to-lymphocyte (PLR) and Neutrophil-to-Lymphocyte (NLR) ratios have been extensively investigated in cancer. However, to date, actual guidelines concerning ovarian cancer are missing. The purpose of the present systematic review is to summarize the available evidence. METHODS: We systematically searched Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016), and Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) databases together with reference lists from included studies. RESULTS: Eighteen studies were included in the present systematic review that involved 3453 patients. According to the current data, both PLR and NLR values in ovarian cancer patients seem to deviate from healthy controls. Furthermore, they may also be indicative of the stage of the disease and of the response to chemotherapy. Nevertheless, their diagnostic accuracy remains limited as their sensitivity and specificity are moderate (detects 55-80% of ovarian cancer women). CONCLUSION: According to the findings of our study, both PLR and NLR seem to be promising screening and prognostic factors of epithelial ovarian cancer. The actual diagnostic cut-off values remain, however, undefined until now. Despite their limited sensitivity and specificity, they might be useful in the future as adjunct biomarkers for the detection and surveillance of the disease.

A systematic review on vaginal laser therapy for treating stress urinary incontinence: Do we have enough evidence?

INTRODUCTION AND HYPOTHESIS: Current treatment strategies for stress urinary incontinence (SUI) raise concerns about safety and efficacy. The purpose of this systematic review was to present available evidence related to vaginal laser therapy as a treatment option for SUI. METHODS: We searched the MEDLINE (1966-2017), Scopus (2004-2017), Clinicaltrials.gov (2008-2017) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2017) databases for relevant studies in this field. We aimed to include all observational studies (prospective and retrospective, randomized and nonrandomized) that reported outcomes on vaginal laser therapy as a treatment option for SUI. RESULTS: Thirteen studies were included that recruited 818 patients who underwent laser therapy for SUI. The methodological quality of most included studies was low, as they were either individual case-control studies, case series or poor-quality cohorts (Oxford Level of Evidence 3b and 4). According to the existing evidence, laser therapy may be a useful, minimally invasive approach for treating SUI. However, the methodological limitations of included studies render them prone to significant bias, limiting their scientific integrity. CONCLUSIONS: As the demand for minimally invasive approaches for treating SUI increases, it is expected that more patients will seek alternative treatments over current standards (midurethral slings). Given the limitations of the existing studies, it seems that conducting future trials is necessary to elucidate this field.

Trends in white blood cell and platelet indices in a comparison of patients with papillary thyroid carcinoma and multinodular goiter do not permit differentiation between the conditions.

AIM: Carcinogenesis has been related to systematic inflammatory response. Our aim was to study white blood cell and platelet indices as markers of this inflammatory response in thyroid cancer and to associate them with various clinicopathological parameters. METHODS: We included 228 patients who underwent thyroidectomy within a period of 54 months, 89 with papillary thyroid carcinoma and 139 with multinodular hyperplasia. We examined potential links between white blood cell and platelet indices on the one hand and the type thyroid pathology and various clinicopathological parameters on the other. RESULTS: No significant differences were detected between thyroid cancer and multinodular hyperplasia and no significant associations were detected with regard to lymphovascular invasion and tumor size. However, the mean platelet volume was higher in multifocal tumors, while the platelet count, plateletcrit, and platelet-to-lymphocyte ratio were increased in cases with extrathyroidal extension and in T3 tumors. Additionally, T3 tumors had lower platelet distribution width. These associations demonstrated low accuracy in predicting these pathological features, but they were found to provide a satisfying negative predictive value, with the exception of the mean platelet volume. CONCLUSIONS: White blood cell and platelet indices cannot assist in distinguishing benign goiter from thyroid cancer. However, they can provide information about tumor multifocality, extrathyroidal extension, and presence of a T3 tumor, and they may be used as a means to exclude these pathological characteristics, especially the last two, in papillary thyroid carcinoma.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma: The European experience.

PURPOSE: The aim of this meta-analysis of studies conducted in Europe was to evaluate the effect of laparoscopic liver resection (LLR) on short- and long-term outcomes compared to open liver resection (OLR) in patients operated for hepatocellular carcinoma (HCC). METHODS: An electronic literature search was conducted in order to identify studies comparing LLR and OLR. Short-term outcomes evaluated included operative time, blood loss, need for transfusion, R0 resection, resection margin width, length of hospital stay, morbidity and 30-day postoperative mortality. Long-term outcomes included 1-year, 3-year, 5-year overall (OS) and disease-free survival (DFS) as well as tumor recurrence rate. RevMan 5.1 software was utilized for statistical meta-analysis. RESULTS: A total of 851 patients from 10 European studies were included in the present meta-analysis reporting for short- and long-term results for LLR and ORL for HCC. Among them 321 (37.7%) underwent laparoscopic hepatectomy and the remaining 530 (62.3%) were operated through open approach. LLR were found to be strongly associated with lower blood loss as well as need for blood transfusion, shorter hospital stay, lower 30-day mortality and morbidity and finally improved 1-year OS and 5-year DFS. Operative time, R0 resection, resection margin width, tumor size, 3- and 5-year OS as well as 1- and 3-year DFS were not found significantly different among the two groups. CONCLUSION: The present meta-analysis demonstrates the superiority of laparoscopic over open approach for same sized tumors. Cirrhotic patients benefit from laparoscopy in terms of shorter hospital stay, complication rate and long-term oncologic outcomes.

Meta-meta-analysis: A paradigm in the case of surgical publications.

PURPOSE: Meta-analyses are considered to provide level I-II evidence. Based on this premise, several statements have been developed to standardize guidelines and optimize results. The purpose of this study was to investigate the quality of the information delivered by meta-analyses. METHODS: Meta-analyses published in Annals of Surgery during an 11-year period were reviewed whereas individual publications of each meta-analysis were assessed. An Excel database encompassing 29 parameters was constructed based on the Quality of Reporting of Meta-analyses (QUOROM) statement. RESULTS: The present study included 31 consecutive meta- analyses. The number of meta-analyses conforming with each of the parameters considered was as follows: information obtained from more than 2 databases 23/31; language of publication exclusively English 25/31; defined population, intervention, and principal outcomes 31/31; study design encompassing review of randomised controlled trials (RCTs) 10/31; quality assessment of contributing publications 10/31; handling of missing data 10/31; assessment of statistical heterogeneity 30/31; subgroup analysis 23/31; assessment of publication bias 26/31; agreement on selection and validity assessment 22/31; simple summary results 28/31; data available to calculate effect size and confidence interval 27/31; key findings summarized 30/31; clinical inferences based on internal and external validity 24/31; description of potential biases in the review process 23/31; future research agenda suggested 18/31. CONCLUSIONS: Evidence derived from meta-analyses must be interpreted with caution. Although QUOROM guidelines were observed, quality assessments showed considerable variability.