Evaluation of two inflammation-based prognostic scores in patients with resectable gallbladder carcinoma.

BACKGROUND: Survival after surgery for gallbladder cancer is generally poor. A number of inflammation-based prognostic scores have been established to help predict survival after surgery for several types of cancer. The objective of this study was to analyze and compare the utility of two inflammation-based prognostic scores, the Glasgow prognostic score (GPS) and the neutrophil-to-lymphocyte ratio (NLR), for predicting survival in patients with gallbladder cancer after surgery with curative intent. METHODS: We retrospectively reviewed the medical records of 85 patients with histologically confirmed, resectable gallbladder carcinoma (GBC), who were to receive curative surgery in our department. Univariate and multivariate analyses were performed to evaluate the relationship between the variables to overall survival (OS). RESULTS: A significant difference was detected in OS in patients with low and high GPS and NLR scores. Univariate analyses using clinicopathological characteristics revealed that tumor differentiation; tumor invasion; lymph node metastasis; tumor, node, metastasis classification system stage; positive margin status; combined common bile duct resection; serum levels of C-reactive protein, albumin, carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen, and CA125; white blood cell count; and GPS and NLR were all associated with OS. Among these characteristics, multivariate analysis demonstrated that a high GPS was independently associated with poorer OS, together with tumor invasion, lymph node metastasis, and positive margin status. CONCLUSIONS: GPS is superior to NLR with respect to its prognostic value for patients with GBC after surgery with curative intent. GPS is not only associated with tumor progression but is also an independent marker of poor prognosis.

The relationship between multiple clinicopathological features and nerve invasion in pancreatic cancer.

BACKGROUND: Nerve invasion is a specific type of tumor expansion and characteristic manifestation of pancreatic cancer (PC), with an incidence rate ranging from 50% to 100%. It is an important prognostic factor for pancreatic cancer, and its early detection is helpful in the management of the disease. This study was undertaken to analyze retrospectively the relationship between neural invasion and multiple clinicopathological features and to provide evidences for clinicians in the management of neural invasion in patients with PC. METHODS: Formalin-fixed paraffin-embeded specimens of PC taken from 215 patients were examined for the presence of neural invasion under a light microscope. Analyzed was the relationship between neural invasion and multiple clinicopathological feature including preoperative fasting blood glucose level, amylase level, serum CA19-9 level, abdominal pain, lumbar and back pain, and the expressions of p53 and Ki67 in tumor tissues. RESULTS: Preoperative fasting blood glucose level, serum CA19-9 level and p53 positive cells in cancer tissue were increased with the rise of pathological grade (P<0.05). These indices were significantly higher in patients with neural invasion than in those without (P<0.05). Further analysis revealed a positive correlation between p53 and Ki67 overexpression and lymphatic metastasis (P<0.05). Referred pain was positively correlated with neural invasion (P<0.05). Patients with PC perineural invasion were more likely to have a higher pathological grade (P<0.05). CONCLUSIONS: Our data indicated that the preoperative fasting blood glucose level, serum CA19-9 level, and referred pain are novel predictive markers for neural invasion in patients with PC. p53 and Ki67 play important roles in neural invasion of PC. Management of hyperglycemia may serve as an auxiliary treatment to curb neural invasion in PC.

Experimental study on operative methods of pancreaticojejunostomy with reference to anastomotic patency and postoperative pancreatic exocrine function.

AIM: To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods. METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. After 4 wk ligation, a total of 36 piglets were divided randomly into four groups. The piglets in the control group underwent laparotomy only; the others were treated by three anastomoses: (1) end-to-end pancreaticojejunostomy invagination (EEPJ); (2) end-to-side duct-to-mucosa sutured anastomosis (ESPJ); or (3) binding pancreaticojejunostomy (BPJ). Anastomotic patency was assessed after 8 wk by body weight gain, intrapancreatic ductal pressure, pancreatic exocrine function secretin test, pancreatography, and macroscopic and histologic features of the anastomotic site. RESULTS: The EEPJ group had significantly slower weight gain than the ESPJ and BPJ groups on postoperative weeks 6 and 8 (P < 0.05). The animals in both the ESPJ and BPJ groups had a similar body weight gain. Intrapancreatic ductal pressure was similar in ESPJ and BPJ. However, pressure in EEPJ was significantly higher than that in ESPJ and BPJ (P < 0.05). All three functional parameters, the secretory volume, the flow rate of pancreatic juice, and bicarbonate concentration, were significantly higher in ESPJ and BPJ as compared to EEPJ (P < 0.05). However, the three parameters were similar in ESPJ and BPJ. Pancreatography performed after EEPJ revealed dilation and meandering of the main pancreatic duct, and the anastomotic site exhibited a variable degree of occlusion, and even blockage. Pancreatography of ESPJ and BPJ, however, showed normal ductal patency. Histopathology showed that the intestinal mucosa had fused with that of the pancreatic duct, with a gradual and continuous change from one to the other. For EEPJ, the portion of the pancreatic stump protruding into the jejunal lumen was largely replaced by cicatricial fibrous tissue. CONCLUSION: A mucosa-to-mucosa pancreatico-jejunostomy is the best choice for anastomotic patency when compared with EEPJ. BPJ can effectively maintain anastomotic patency and preserve pancreatic exocrine function as well as ESPJ.

[Implication of different expression of IL-2 mRNA and IL-10 mRNA in CD4(+)CD25(+)T cell induced immune tolerance of liver transplantation in rat].

OBJECTIVE: To investigate the expression of tolerance-associated interleukin (IL)-2 mRNA and IL-10 mRNA in rats after allogeneic liver transplantation. METHODS: The experimental rats were randomly divided into 3 groups: acute rejection model group (group I), CD4(+)CD25(+)T cell treatment group (group II), donors of the two groups were Wistar while recipients were Sprague-Dawley (SD) rats, and group III as control group, both donors and recipients of this group were SD rats, with 12 rats in each group. Splenic lymphocyte of donor in group II were injected through vena dorsalis penis 7 days before liver transplantation; equal volume normal saline (NS) were injected in rats of group I and III. The contents of IL-2 mRNA and IL-10 mRNA in the liver tissue were determined by reverse transcription-polymerase chain reaction (RT-PCR), and the number of lymphocytes in the donor liver was quantified with flow cytometry 7 days after transplantation. Meanwhile the pathologic change in the donor tissue were observed, and the recipients' life span was recorded. RESULTS: IL-2 mRNA was expressed strongly in the liver of group I, but it was expressed weakly in group II, and no expression was detected in the liver of group III. IL-10 mRNA was expressed only in group II, and the level was high. The rats in group II and III survived over 30 days, but rats in group I had a shorter life (8-11 days, both P<0.01). There was heavy lymphocytic infiltration in the liver of group I,and was much higher than that of the other groups [group I:(14.31+/-3.41)x10(6)/g, group II: (5.04+/-1.13) x10(6)/g, group III: (1.55+/-0.40) x10(6)/g, all P<0.01], and pathology showed moderate rejection. Rats in group II had milder lymphocytic infiltration, and pathology showed no signs of rejection or uncertain rejection, and the ratio of CD4(+) T cell and CD4(+)CD25(+) were higher than those of group I [(43.31+/-8.07)% vs. (33.65+/-7.25)% and (11.39+/-1.92)% vs. (3.05+/-0.62)%] and group III [(43.31+/-8.07)% vs. (31.18+/-6.25)% and (11.39+/-1.92)% vs. (3.37+/-0.72)%, P<0.05 or P<0.01]. In group III no lymphocytic infiltration was found, and pathology showed no sign of rejection. CONCLUSION: IL-2 may participate in the immune rejection in allogeneic liver transplantation, but IL-10 plays an important role in CD4(+)CD25(+) T cell inducing immune tolerance of allogeneic liver transplantation in the rats.

Hypoxia inducible factor-1alpha mediates protective effects of ischemic preconditioning on ECV-304 endothelial cells.

AIM: To investigate whether hypoxia inducible factor-1alpha (HIF-1alpha) is linked to the protective effects of ischemic preconditioning (IP) on sinusoidal endothelial cells against ischemia/reperfusion injury. METHODS: Sinusoidal endothelial cell lines ECV-304 were cultured and divided into four groups: control group, cells were cultured in complete DMEM medium; cold anoxia/warm reoxygenation (A/R) group, cells were preserved in a 4 centigrade UW solution in a mixture of 95% N2 and 5% CO2 for 24 h; anoxia-preconditioning (APC) group, cells were treated with 4 cycles of short anoxia and reoxygenation before prolonged anoxia-preconditioning treatment; and anoxia-preconditioning and hypoxia inducible factor-1alpha (HIF-1alpha) inhibitor (I-HIF-1) group, cells were pretreated with 5 microm of HIF-1alpha inhibitor NS398 in DMEM medium before subjected to the same treatment as group APC. After the anoxia treatment, each group was reoxygenated in a mixture of 95% air and 5% CO2 incubator for 6 h. Cytoprotections were evaluated by cell viabilities from Trypan blue, lactate dehydrogenase (LDH) release rates, and intracellular cell adhesion molecule-1 (ICAM-1) expressions. Expressions of HIF-1alpha mRNA and HIF-1alpha protein from each group were determined by the RT-PCR method and Western blotting, respectively. RESULTS: Ischemia preconditioning increased cell viability, and reduced LDH release and ICAM-1 expressions. Ischemia preconditioning also upregulated the HIF-1alpha mRNA level and HIF-1alpha protein expression. However, all of these changes were reversed by HIF-1alpha inhibitor NS398. CONCLUSION: Ischemia preconditioning effectively inhibited cold hypoxia/warm reoxygenation injury to endothelial cells, and the authors showed for the first time HIF-1alpha is causally linked to the protective effects of ischemic preconditioning on endothelial cells.

[Combination of CD4+ CD25+ regulatory T cell and costimulatory pathway blockade inhibits acute rejection after liver transplantation: experiment with rats].

OBJECTIVE: To investigate the effect of CD4+ CD25+ regulatory T cell (Treg) combined with anti-CD154 mAb, a costimulatory pathway inhibitor, on acute rejection after liver transplantation. METHODS: CD4+ T cells were isolated from the spleen of a Lewis rat and labeled with CD25-PE antibody. Anti-PE microbeads were added to collect CD4+ CD25+ T cells. Splenocytes were isolated form DA rat, treated with mitomycin C, and then co-cultured with the CD4+ CD25+ T cells of Lewis rat for 5 days for ex vivo activation. Forty-eight Lewis rats received orthotopic transplantation of the livers of DA rats, and then were randomly divided into 4 equal groups: Group A, used as control group, Group B, undergoing intravenous injection of the CD4+ CD25+ Treg activated ex vivo by splenocytes of DA rat 7 days before the liver transplantation, Group C, undergoing intraperitoneal injection of anti-CD154 mAb twice 1 and 2 days after the liver transplantation, and Group D, undergoing injection of both CD4+ CD25+ Treg and anti-CD154. Seven days after the transplantation 6 Lewis rats in each group were harvested to observe the pathological changes of the livers and to detect the infiltrating lymphocytes, and CD4+, CD8+, and CD4+ CD25+ T cells. RT-PCR was used to detect the mRNA expression of IL-2, IL-4, IL-10, and TGFbeta1 in the liver. Mixed lymphocyte reaction (MLR) was performed to evaluate the tolerance status. The remaining rats were used to observe the survival status. RESULTS: The mean survival time of Group D was 52.00 +/- 10.64 days, significantly longer than those of the other three groups (P < 0.05 or P < 0.01). Seven days after transplantation, the number of infiltrating lymphocytes in liver of Group D was significantly lower than those in the other 3 groups (P < 0.05 or P < 0.01), whereas the proportion of CD4+ CD25+ T cells was significantly higher than those of the other 3 groups (P < 0.01 or P < 0.05). The mRNA expression levels of IL-10 and TGFbeta1 of Group D were both the highest, however, the mRNA level of IL-2 of Group D was the lowest. The MLR assay with the splenocytes of DA rat as stimulatory cells demonstrated that the SI of Group D was, significantly lower than those of other 3 groups (all P < 0.05), however, the MLR assay with the splenocytes of Wistar rat as stimulatory cells demonstrated that there were not significant differences among the SI levels of the 4 groups (all P > 0.05). CONCLUSION: Acute rejection after liver transplantation can be inhibited by CD4+ CD25+ Treg and costimulatory pathway inhibitor, especially the combination of both. Anti-CD154 mAb significantly enhances the effect of CD4+ CD25+ Treg on inhibition of.

Establishment of a new pig model for auxiliary partial orthotopic liver transplantation.

AIM: To establish a new pig model for auxiliary partial orthotopic liver transplantation (APOLT). METHODS: The liver of the donor was removed from its body. The left lobe of the liver was resected in vivo and the right lobe was used as a graft. After the left lateral lobe of the recipient was resected, end-to-side anastomoses of suprahepatic inferior vena cava and portal vein were performed between the donor and recipient livers, respectively. End-to-end anastomoses were made between hepatic artery of graft and splenic artery of the host. Outside drainage was placed in donor common bile duct. RESULTS: Models of APOLT were established in 5 pigs with a success rate of 80%. Color ultrasound examination showed an increase of blood flow of graft on 5(th) d compared to the first day after operation. When animals were killed on the 5(th) d after operation, thrombosis of hepatic vein (HV) and portal vein (PV) were not found. Histopathological examination of liver samples revealed evidence of damage with mild steatosis and sporadic necrotic hepatocytes and focal hepatic lobules structure disorganized in graft. Infiltration of inflammatory cells was mild in portal or central vein area. Hematologic laboratory values and blood chemical findings revealed that compared with group A (before transplantation), mean arterial pressure (MAP), central venous pressure (CVP), buffer base (BB), standard bicarbonate (SB) and K(+) in group B (after portal vein was clamped) decreased (P<0.01). After reperfusion of the graft, MAP, CVP and K(+) restored gradually. CONCLUSION: Significant decrease of congestion in portal vein and shortened blocking time were obtained because of the application of in vitro veno-venous bypass during complete vascular clamping. This new procedure, with such advantages as simple vessel processing, quality anastomosis, less postoperative hemorrhage and higher success rate, effectively prevents ischemia reperfusion injury of the host liver and deserves to be spread.

[Effect of heme oxugenase-1 on delayed xenograft rejection: experiment of guinea pig-to-rat liver xenotransplantation].

OBJECTIVE: To investigate the effects and mechanism of heme oxygenase-1 (HO-1) in liver xenotransplantation and mechanism thereof. METHODS: Thirty male guinea-pigs used as donors were injected intravenously with cobra venom factor (CVF) and then randomly divided into 3 groups 24 hours after: Group A injected intraperineally with NaCl, Group B injected intraperineally with cobalt-protoporphyrin (CoPP), heme oxygenase-1 inducer, and Group C injected intraperineally with CoPP and zinc protoporphyrin (ZnPP), HO-1 inhibitor zinc before their livers were harvested. Thirty male SD rats used as recipients underwent the above-mentioned treatment 24 hours before receiving the xenografts. Five pairs of guinea pigs and rats in each group underwent collection of blood and liver tissues 3 hours after the recovery of blood perfusion in the transplanted livers for detection of serum enzymes by biochemical methods and expression of HO-1 mRNA and protein in the transplanted livers by RT-PCR and Western blotting respectively. The other 5 pairs in each group were used to observe the survival time. RESULTS: The survival time of Group B was 15.5 h +/- 3.8 h, significantly longer than those of Group A (7.3 h +/- 2.1 h) and Group C (6.7 h +/- 2.9 h, both P < 0.01). The values of ALT and LDH of Group B were significantly lower than those of Group A and C (all P < 0.05). HOI-1 mRNA expression was not detected or only expressed in trace amount in the livers of normal guinea pigs, expressed in a small amount in the transplanted livers of Group A. The expression of HO-1 mRNA and that of HO-1 protein in the transplanted livers of Group B were significantly higher than those of Group A (both P < 0.01), and the expression of HO-1 mRNA and that of HO-1 protein in the transplanted livers of Group C were not significantly different from those of Group A (both P > 0.05). Remarkable NF-kB band was detected in Groups A and C, and only weak NF-kB band was seen in Group B. The E-selectin expression was significantly lower in the transplanted livers of Group B than in those of Group A and C (both P < 0.05). CONCLUSION: HO-1 delays the occurrence of delayed xenograft rejection in liver xenotransplantation. This effect depends, at least in part, on HO-1-mediated inhibition of endothelium activation in xenografts.

A ten-year study on non-surgical treatment of postoperative bile leakage.

AIM: To summarize systematically our ten-year experience in non-surgical treatment of postoperative bile leakage, and explore its methods and indications. METHODS: The clinical data of 57 patients with postoperative bile leakage treated non-surgically from January 1991 to December 2000 were reviewed retrospectively. RESULTS: The site of the leakage was mainly the disrupted or damaged fistulous tracts of T tube in 25 patients (43.9 %), the fossae of gallbladder in 14 cases (24.6 %), the cut surface of liver in 7 cases(12.3 %), and it was undetectable in the other 2 cases. Besides bile leakage, the wrong ligation of bile ducts was found in 3 patients, residual stones of the distal bile duct in 5 patients, benign papillary strictures in 3, and biloma resulting from bile collections in 2. The diagnoses were made according to the history of surgery, clinical situation, abdominal paracentesis, ultrasonography, ERCP, PTC, MRI/MRCP, gastroscopy and percutaneous fistulography. All 57 patients were treated non-surgically at the beginning of bile leakage. The non-surgical methods included keeping original drainage unobstructed, percutaneous abdominal paracentesis or drainage, percutaneous transhepatic cholangial/biliary drainage (PTCD/PTBD),endoscopic management, traditional Chinese medicine and so on. Of the 57 patients,2 patients died,5 were converted to reoperation later, the other 50 were directly cured by non-surgical methods without any complication. The cure rate of the non-surgery was 82.5 %(50/57). CONCLUSION: Many nonoperative methods are available to treat postoperative bile leakage. Non-surgical treatment may serve as the first choice for the treatment of bile leakage for its advantages in higher cure rate, convenience and safety in practice. It is important to choose the specific non-surgical method according to the volume, site of bile leakage and patient's condition.

[Preliminary experimental study on treatment of portal hypertension with auxiliary partial orthotopic liver transplantation].

OBJECTIVE: To evaluate the therapeutic efficacy of auxiliary partial orthotopic liver transplantation (APOLT) on portal hypertension in liver cirrhosis with amelioration of portal vein congestion, changes in portal vein pressure and status of the graft. METHODS: The recipients were porcine model of biliary cirrhosis reproduced by ligation of the common bile duct. During transplantation, arterial blood pressure, central venous pressure were recorded. Buffer base, standard bicarbonate and pH of arterial blood samples were determined and analyzed in order to assess the impact of operation on the animals. The hemodynamics were also monitored. Color Doppler ultrasonographic examination was performed on recipients before operation, intra-operation and 7 days after operation, respectively. Portal vein pressure, blood bilirubin and variables of liver function were measured by using an autoanalyzer. Wedge biopsy specimens of each pig were obtained, stained with hematoxylin-eosin, and examined. Analysis of variance was performed. Otherwise non-parametric tests were used. RESULTS: Eight weeks after ligation of the common bile duct, biliary cirrhosis was reproduced in all the pigs, and histopathological examination of the liver specimen showed a large number of pseudo-lobules. In 6 pigs with hepatic cirrhosis liver transplantation was done. Five of the 6 (83.3%) animals survived for 7 days. One recipient died because of unsuccessful operation, the others showed stable hemodynamics during the operation. Seven days after transplantation, the blood flow of the two liver portal veins was observed by the use of color Doppler ultrasonography. It was found that the blood flow in the donor portal vein was much richer than that of native portal vein. The venous outflow of the graft was ample and smooth, and no thrombosis of the hepatic vein or portal vein was found. The variables, including alanine aminotransferase, aspartate aminotransferase, bilirubin and total bilirubin, were significantly improved 7 days after operation compared with pre-operative data. Portal pressure was found to be (20.76+/-2.42)cm H(2)O(1 cm H(2)O=0.098 kPa), (17.62+/-2.33)cm H(2)O and (14.72+/-2.25)cm H(2)O before the operation, during the operation, and 7 days after operation, respectively, and the difference was statistically significant(P<0.01). On the 7 days after transplantation, histopathological examination revealed evidence of damage with mild steatosis and sporadic necrotic hepatocytes and focal hepatic lobular degeneration in the graft, especially in the area around the central vein. CONCLUSION: APOLT is a hopeful option for the treatment of portal hypertension. This procedure can provide not only some improvement of the liver function but also decrease the pressure of portal vein.

[Wound healing after pancreaticojejunostomy in piglets: a comparison between two anastomotic methods].

OBJECTIVE: To evaluate wound healing after types of pancreaticojejunostomy. METHODS: After resection of the pancreatic head, 38 domestic piglets were divided into two groups according to the types of anastomoses: group I: binding pancreaticojejunostomy, a new technique designed and advocated by professor Peng Shuyou; group II: end-to-end pancreaticojejunal invagination. Anastomotic strength in vivo and histopathological findings were assessed on operative day and postoperative day 5 and 10. RESULTS: Bursting pressure was 139.7 +/- 8.0, 178.7 +/- 9.7 and 268.8 +/- 12.8 mm Hg in group I on day 0, 5 and 10, whereas 67.3 +/- 7.9, 96.2 +/- 10.4 and 130.6 +/- 9.3 mm Hg in group II. The gain on day 0 to 5 and 5 to 10 was 27.9% and 50.5% in group I and 42.9% and 35.7% in group II, respectively. A significant difference was observed between group I and group II, and between 5 and 10 day after anastomoses (P < 0.01). Breaking strength was 4.5 +/- 0.4, 6.6 +/- 0.4 and 10.0 +/- 0.6 N in group I on day 0, 5 and 10 and 4.6 +/- 0.6, 5.8 +/- 0.5 and 7.1 +/- 0.6 N in group II. Although a similar value was shown in both types of anastomoses on day 0, a rapider gain was demonstrated on day 0 to 5 and 5 to 10 in group I (44.8% and 52.9%) than in group II (25.4% and 22.0%). A significant difference was found on day 5 and 10 between the two types of anastomoses (P < 0.05 and P < 0.01). Anastomotic site was well repaired by connective tissue and the cut surface of pancreatic stump was covered by mucosal epithelium in group I on day 10, but the cut surface was incompletely repaired by granulation tissue and no, regeneration of the epithelium was found in group II. CONCLUSION: Anastomotic strength of binding pancreaticojejunostomy was stronger than end-to-end pancreaticojejunal invagination and the healing was better and rapid.

Effect of siRNA-mediated knockdown of eIF3c gene on survival of colon cancer cells.

Eukaryotic initiation factor subunit c (eIF3c) has been identified as an oncogene that is over-expressed in tumor cells and, therefore, is a potential therapeutic target for gene-based cancer treatment. This study was focused on investigating the effect of small interfering RNA (siRNA)-mediated eIF3c gene knockdown on colon cancer cell survival. The eIF3c gene was observed to be highly expressed in colon cancer cell models. The expression levels of the gene in eIF3c siRNA infected and control siRNA infected cells were compared via real-time polymerase chain reaction (PCR) and western blotting analysis. Cell proliferation levels were analyzed employing 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and colony formation assays. Furthermore, the effects of eIF3c gene knockdown on the cell cycle and apoptosis were analyzed using flow cytometry. The results showed that suppression of eIF3c expression significantly (P<0.001) reduced cell proliferation and colony formation of RKO colon cancer cells. The cell cycle was arrested by decreasing the number of cells entering S phase. Further, apoptosis was induced as a result of eIF3c knockdown. Collectively, eIF3c deletion effectively reduced the survival of colon cancer cells and could be used as a therapeutic tool for colon cancer therapy.

Single-incision laparoscopic cholecystectomy versus multi-incision laparoscopic cholecystectomy: a meta-analysis of randomized clinical trials.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) is theoretically supposed to be associated with better cosmetic results and less surgical-site pain than multi-incision laparoscopic cholesystectomy (MILC). So far, several relevant randomized controlled trials (RCTs) have been reported, but the results are conflicting. MATERIALS AND METHODS: Meta-analysis was conducted with all the qualified RCTs comparing SILC with MILC. The databases include PubMed, EmBase, and the Cochrane Library, and the censor data were collected up to November 2011. The analyzed outcome variables included postoperative pain score, analgesia requirements, morbidity, conversion rate, operative time, postoperative hospital stay, and postoperative cosmetic score. Analyses were based on the intention-to-treat principle, if possible. All the calculations and statistical tests were performed using ReviewerManager version 5.1.2 software. RESULTS: Nine trials with a total of 755 patients (SILC in 400 patients, MILC in 355 patients) were identified and analyzed. SILC resulted in significantly longer operative time (P=.005) and higher postoperative cosmetic score on Day 30 after operation (P<.00001). There was no statistically significant difference between the groups in terms of postoperative pain score, analgesia requirements, morbidity, conversion rate, and postoperative hospital stay. CONCLUSIONS: Based on the current meta-analysis, SILC appears to be as safe and effective as MILC to remove the gallbladder and results in a longer operative time and higher cosmetic satisfaction on Day 30 after surgery.