The Role of Enhanced Recovery after Surgery in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis.

INTRODUCTION: This study aimed to compare the safety and short-term outcomes of Enhanced Recovery After Surgery (ERAS) with standard care for patients undergoing pancreatoduodenectomy (PD) based on literature published following the first publication of ERAS guidelines for PD. METHODS: Five medical databases were searched for studies that compared ERAS to standard care in adults undergoing PD. Data on postoperative complications, length of hospitalization, readmissions, and time to chemotherapy were analyzed using either a fixed- or random-effects model meta-analysis. Meta-regressions were conducted to investigate the role of operative technique, study origin, and study design. RESULTS: Our analysis included 22 studies involving 4,043 patients. ERAS was associated with fewer complications (relative risk [RR]: 0.83; 0.75-0.91), particularly Clavien-Dindo (CD) grade 1 and 2 complications (RR: 0.82; 0.72-0.92), delayed gastric emptying (RR: 0.69; 0.52-0.93), and postoperative fistula (POPF) (RR: 0.76; 0.66-0.89), and a shorter time to chemotherapy (standardized mean difference [SMD]: -0.68; 95% CI: -0.88 to -0.48). ERAS did not affect the risk for CD grade 3 and 4 complications (RR: 1.00; 0.72-1.38), post-pancreatectomy hemorrhage (RR: 0.88; 0.67-1.14), length of stay (SMD: -0.56; 95% CI: -1.12 to 0.01), readmission (RR: 1.01; 0.84-1.21), and mortality (RR: 0.81; 0.54-1.22). The continent of origin was an effect moderator in the role of ERAS in CD grade 1 and 2 complications (p = 0.047) and POPF (p = 0.02). CONCLUSION: Implementing ERAS principles in PD improves surgical outcomes without compromising safety. ERAS may also accelerate time to chemotherapy, an essential issue for future research.

From Classic Whipple to Pylorus Preserving Pancreaticoduodenectomy and Ultimately to Pylorus Resecting - Stomach Preserving Pancreaticoduodenectomy: A Review.

Pancreaticoduodenectomy is the procedure of choice for benign or malignant tumors of the periampullary region. The preservation of the pylorus has been established as the mostly utilized approach during pancreaticoduodenectomy among the majority of specialized, in the surgical treatment of pancreatic cancer, centers worldwide. The factors that influenced this predilection are the shorter operation times, the less intraoperative blood loss, the decreased technical difficulty, and the quite similar short- and long-term outcomes compared to the classic Whipple. However, there is a notable trend in the literature highlighting the increased incidence of delayed gastric emptying following pylorus preserving pancreaticoduodenectomy. Among other factors, pylorus dysfunction attributable to the surgical maneuvers has been implemented in the etiology of this complication. In an attempt to overcome this limitation of the pylorus preserving pancreaticoduodenectomy, pylorus resecting pancreaticoduodenectomy with the preservation of the stomach was proposed. In theory, pylorus resecting pancreaticoduodenectomy could maintain the advantages of organ sparing surgery, but at the same time guarantee a more seamless gastric emptying. Only three RCTs, to date, aimed to evaluate the approach with only one reporting results in favor of the pylorus resecting pancreaticoduodenectomy in regard to the incidence of delayed gastric emptying. Further well-designed prospective randomized studies are needed for an accurate assessment of the true role of each of these surgical alternatives on the treatment of pancreatic cancer.

The Immunomodulatory Effect of Various Anaesthetic Practices in Patients Undergoing Gastric or Colon Cancer Surgery: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: Gastric and colorectal carcinomas are associated with increased mortality and an increasing incidence worldwide, while surgical resection remains the primary approach for managing these conditions. Emerging evidence suggests that the immunosuppression induced by the chosen anaesthesia approach, during the perioperative period, can have a significant impact on the immune system and consequently the prognosis of these patients. AIM: This systematic review aims to comprehensively summarize the existing literature on the effects of different anaesthesia techniques on immune system responses, focusing on cellular immunity in patients undergoing the surgical removal of gastric or colorectal carcinomas. There is no meta-analysis investigating anaesthesia's impact on immune responses in gastric and colorectal cancer surgery. Anaesthesia is a key perioperative factor, yet its significance in this area has not been thoroughly investigated. The clinical question of how the anaesthetic technique choice affects the immune system and prognosis remains unresolved. METHODS: Major electronic databases were searched up to February 2023 to May 2023 for relevant randomized controlled trials (RCTs). The study protocol has been registered with Prospero (CRD42023441383). RESULTS: Six RCTs met the selection criteria. Among these, three RCTs investigated the effects of volatile-based anaesthesia versus total intravenous anaesthesia (TIVA), while the other three RCTs compared general anaesthesia alone to the combination of general anaesthesia with epidural anaesthesia. According to our analysis, there were no significant differences between TIVA and volatile-based anaesthesia, in terms of primary and secondary endpoints. The combination of general anaesthesia with epidural analgesia had a positive impact on NK cell counts (SMD 0.61, 95% CI 0.28 to 0.94, I2 0.0% at 24 and 72 h after the operation), as well as on CD4+ cells (SMD 0.59, CI 95% 0.26 to 0.93, I2 0.0%). However, the CD3+ cell count, CD4+/CD8+ ratio, neutrophil-to-lymphocyte ratio (NLR), IL-6 and TNF-α levels remained unaffected. CONCLUSIONS: The combination of epidural analgesia and general anaesthesia can potentially improve, postoperatively, the NK cell count and CD4+ cell levels in gastric or colon surgery patients. However, the specific impact of TIVA or volatile-based anaesthesia remains uncertain. To gain a better understanding of the immunomodulatory effects of anaesthesia, in this particular group of cancer patients, further well-designed trials are required.

Surgery and Reason: The End of History and the Last Surgeon.

Arguably, Georg Wilhelm Friedrich Hegel has been one of the most influential philosophers of the 19th century [...].

The role of systematic pelvic and para-aortic lymphadenectomy in the management of patients with advanced epithelial ovarian, tubal, and peritoneal cancer: A systematic review and meta-analysis.

OBJECTIVE: To investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates in patients with advanced epithelial ovarian cancer (EOC), tubal, or peritoneal cancer. METHODS: We searched the electronic databases PubMed (from 1996), Cochrane Central Register of Controlled trials (from 1996), and Scopus (from 2004) to September 2021. We considered randomised controlled trials (RCTs) comparing systematic pelvic and para-aortic lymphadenectomy with no lymphadenectomy in patients with advanced EOC. Primary outcomes were overall survival and progression-free survival. Secondary outcomes were peri-operative morbidity and operative mortality. The revised Cochrane tool for randomised trials (RoB 2 tool) was utilised for the risk of bias assessment in the included studies. We performed time-to-event and standard pairwise meta-analyses, as appropriate. RESULTS: Two RCTs with a total of 1074 patients were included in our review. Meta-analysis demonstrated similar overall survival (HR = 1.03, 95% CI [0.85-1.24]; low certainty) and progression-free survival (HR = 0.92, 95% CI [0.63-1.35]; very low certainty). Regarding peri-operative morbidity, systematic lymphadenectomy was associated with higher rates of lymphoedema and lymphocysts formation (RR = 7.31, 95% CI [1.89-28.20]; moderate certainty) and need for blood transfusion (RR = 1.17, 95% CI [1.06-1.29]; moderate certainty). No statistically significant differences were observed in regard to other peri-operative adverse events between the two arms. CONCLUSIONS: Systematic pelvic and para-aortic lymphadenectomy is likely associated with similar overall survival and progression-free survival compared to no lymphadenectomy in optimally debulked patients with advanced EOC. Systematic lymphadenectomy is also associated with an increased risk for certain peri-operative adverse events. Further research needs to be conducted on whether we should abandon systematic lymphadenectomy in completely debulked patients during primary debulking surgery.

Averting an Unnecessary Revision of a Roux-en-Y Hepaticojejunostomy by Surgically Creating an Access Point for the Endoscopic Assessment of the Anastomosis: A Report of a Case.

Introduction: Primary sclerosing cholangitis sets the scene for several pathologies of both the intrahepatic and the extrahepatic biliary tree. Surgical treatment, when needed, is almost unanimously summarized in the creation of a Roux-en-Y hepaticojejunostomy, a procedure with a relatively high associated failure rate. Presentation of case: A 70-year-old male, diagnosed with primary sclerosing cholangitis, was submitted to a Roux-en-Y hepaticojejunostomy due to a dominant stricture of the extrahepatic biliary tree. Recurrent episodes of acute cholangitis dictated a workup in the direction of a possible stenosis at the level of the anastomosis. The imaging studies were inconclusive while both the endoscopic and the transhepatic approach failed to assess the status of the anastomosis. A laparotomy, with the intent to revise a high suspicion for stenosis hepaticojejunostomy, was decided. Intraoperatively, a decision to assess the hepaticojejunostomy prior to the scheduled surgical revision, via endoscopy, was made. In this direction, an enterotomy was made on the short jejunal blind loop in order to gain luminal access and an endoscope was propelled through the enterotomy towards the biliary enteric anastomosis. Results: The inspection of the anastomosis under direct endoscopic vision showed no evidences of stenosis and averted an unnecessary, under these circumstances, revision of the anastomosis. Conclusions: The surgical revision of a Roux-en-Y hepaticojejunostomy is a highly demanding operation with an increased associated morbidity, and it should be reserved as the final resort in the treatment algorithm. An approach of utilizing surgery to facilitate the endoscopic assessment prior to proceeding to the surgical revision of the anastomosis appears justified.

Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study.

BACKGROUND: Several surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan-Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) technique. METHODS: A retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL-RAR group. Primary end points were recurrence rates and patients' satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables. RESULTS: A total of 124 patients were identified, submitted either to HAL-RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females-male / female ratio: 3.6) with a median age of 47 years old (range 18-69) were included in the HAL-RAR group while 47 patients (40 males and 7 females-male / female ratio: 5.7) with a median age of 52 years old (range 32-71) comprised the MM group. At a median follow up of 41 months (minimum 24 months-maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL-RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL-RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99-p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70-p 0.0013) in the HAL-RAR group. CONCLUSIONS: In patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL-RAR. In patients with bleeding as the main presenting symptom of HD, HAL-RAR was associated with better patients' satisfaction rates and similar recurrence rates compared to MM.

Colorectal Cancer Liver Metastases: Is an R1 Hepatic Resection Accepted?

Metastatic colorectal cancer is associated with a rather dismal 5-year overall survival. The liver is the most commonly affected organ. Improved 5-year survival rates after successful hepatic resections for metastases confined to the liver have been reported. Certainly, a hepatectomy that results in an incomplete tumor resection, in terms of leaving macroscopic residual tumor in the future liver remnant, is not associated with survival benefits. However, the prognostic implications of a microscopically positive surgical margin or a clear margin of less than 1 mm (R1) on pathology are debatable. Although it has been a field of extensive research, the relevant literature often reports contradictory results. The purpose of the present study was to define, assess the risk factors for, and, ultimately, analyze the effect that an R1 hepatic resection for colorectal cancer liver metastases might have on local recurrence rates and long-term prognosis by reviewing the relevant literature. Achieving an R0 hepatic resection, optimally with more than 1 mm of clear margin, should always be the goal. However, in the era of the aggressive multimodality treatment of liver metastatic colorectal cancer, an R1 resection might be the cost of increasing the pool of patients finally eligible for resection. The majority of literature reports have highlighted the detrimental effect of R1 resections on local recurrence and overall survival. However, there are indeed studies that degraded the prognostic handicap as a consequence of an R1 resection in selected patients and highlighted the presence of RAS mutations, the response to chemotherapy, and, in general, factors that reflect the biology of the disease as important, if not the determinant, prognostic factors. In these patients, the aggressive disease biology seems to outperform the resection margin status as a prognostic factor, and the recorded differences between R1 and R0 resections are equalized. Properly and accurately defining this patient group is a future challenge in the field of the surgical treatment of colorectal cancer liver metastases.

Computed tomography-guided percutaneous cholecystostomy: a single institution's 6-year experience.

Background: Acute cholecystitis (AC) is an emergency commonly managed by a surgical department. The interventional part of the standard treatment algorithm includes laparoscopic or open cholecystectomy. Percutaneous cholecystostomy (PC) under imaging guidance is recommended as the first-line approach in the subset of high-risk patients for perioperative complications, as a bridging therapy to elective surgery or as a definitive solution. The aim of the present study was to evaluate the mortality and morbidity of PC performed under computed tomographic (CT) guidance in patients at high surgical risk. Methods: Medical and imaging records from all consecutive patients who underwent a CTPC between 2015 and 2020 were reviewed. Adult patients with a definite indication for CTPC were recruited and mortality 7 and 30 days post-procedure was recorded. Variables potentially affecting those outcomes were retrieved and included in our analysis. Results: Eighty-six consecutive patients at high risk for surgical management were identified and included in the present study. Most patients (58.1%) were diagnosed with AC, while 14 (16.3%) had concurrent AC and cholangitis, 13 (15.2%) gallbladder empyema, and 9 (10.4%) hydrops. The 7- and 30-day mortality rates were 16.3% (14/86) and 22.1% (19/86), respectively, and were significantly associated with patients' hospitalization in the intensive care unit (P<0.05). Other parameters investigated, such as age, sex, diagnosis, catheter diameter, and duration of hospital stay were not significantly associated with our primary outcome. Conclusion: PC is a safe alternative to surgery in patients with high perioperative risk, thus providing acceptable mortality rates.

Gastric Cancer Invading the Pancreas: A Review of the Role of Pancreatectomy.

Gastric cancer is quite a common type of cancer, with significant associated mortality. Traditionally, combined resections of affected organs have been advocated in cases of locally advanced gastric cancer, in order to achieve an R0 resection. The purpose of the present study was to evaluate the role of pancreatectomy in the treatment of gastric cancer invading the pancreas by reviewing the relevant literature. The oncological benefits to survival rates of multivisceral resection are not always obvious from the relevant survival charts, especially when the pancreas is the organ invaded by the gastric cancer and gastrectomy needs to be combined with a pancreatectomy, an operation with high morbidity rates. In conclusion, careful patient selection is essential to achieving optimal results, balancing the oncological benefits in these properly selected patients against the associated morbidity of extensive resection.

Extent of Surgical Resection for Gastric Cancer: The Safety Distance Between the Tumor and the Proximal Resection Margin.

A potentially curative treatment scheme for gastric cancer is considered futile without a proper surgical resection. An oncological, surgical resection for gastric cancer prerequisites a proper resection of the stomach, and a D2 lymph node dissection followed by reconstruction of the gastrointestinal tract continuity. Recently, as the favorable impact of organ preserving surgery on functional outcomes has been increasingly appreciated; distal gastrectomy represents a valid alternative to total gastrectomy provided that the proper oncological principles are not violated. However, the appropriateness of distal gastrectomy as a valid type of resection becomes synonymous with achieving a negative proximal resection margin. The purpose of the present study was to assess the optimal distance between the tumor and the resection margin in a gastrectomy with curative intent, performed for gastric cancer, by reviewing the relevant literature. Having in mind, the well documented discrepancy between the gross and the pathologic boundaries of the tumor, pitfalls might be encountered. Current published guidelines have used a "safety distance" i.e., >4 or 5 cm between the proximal macroscopic tumor border and the proximal resection margin in order to guarantee a negative resection margin on pathology. An increased distance of safety is currently proposed in high-risk tumors such as tumors of the diffuse histological type.

Gut Barrier Disruption Secondary to Radiofrequency-Assisted Liver Parenchyma Resection in a Porcine Model.

BACKGROUND: Radiofrequency-assisted liver resection (RF-LR) techniques minimize intraoperative blood loss, while avoiding the Pringle maneuver. Both surgical excision and radiofrequency ablation of liver parenchyma compromise gut barrier function with subsequent bacterial translocation. The present study sought to investigate in a porcine model the impact of two RF-LR techniques on the integrity and inflammatory response of the gut barrier. METHODS: Twenty-four pigs were subjected to either (a) partial hepatectomy (PH) employing the "sequential coagulate-cut" technique using a monopolar electrode (SCC group), the one using the bipolar Habib-4X device (group H), or the "crush-clamp" technique (group CC) or (b) sham operation (group Sham). At 48-h post-operation, ileal tissue was excised to be subjected to histopathologic examination, histomorphometric analysis, and immunohistochemical assessment of the mitotic and apoptotic activities and the expression of interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and nuclear factor-κB (NFκΒ). RESULTS: Histopathologic score increased in all PH groups, being higher in group SCC, while lower in group H. Villous height decreased in group SCC only. Mitotic index decreased, while apoptotic index increased in all PH groups. An increase in tissue expression score was noted for IL-6 in group CC, for TNFα in all PH groups, being lower in group H compared to group CC, and for NFκB in all PH groups. CONCLUSIONS: The Habib-4X technique for liver resection proved to preserve the integrity of gut barrier, being less injurious in the intestinal mucosa compared to the SCC and CC techniques.

A meta-analysis evaluating contrast-enhanced intraoperative ultrasound (CE-IOUS) in the context of surgery for colorectal liver metastases.

BACKGROUND: This study aimed to assess the outcomes of contrast-enhanced intraoperative ultrasound (CE-IOUS) for patients with colorectal liver metastases (CRLMs) undergoing surgery. METHOD: A thorough literature search was performed in PubMed, Scopus, and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated, by means of Random-Effects model. RESULTS: Eleven articles met the inclusion criteria and incorporated 497 patients. The present study shows that CE-IOUS is associated with higher sensitivity and accuracy compared with multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and intraoperative ultrasound (IOUS) in identifying CRLMs (p < 0.05). The positive predictive value was similar among the different modalities. Furthermore, new CRLMs were identified by CE-IOUS, thus affecting the surgical plan in 128 patients (51.8% of the patients with new CRLMs). Moreover, 91 patients (71%) underwent a more extensive hepatectomy and 15 patients (11.7%) were considered non-operable. Two alternative contrast agents, Sonazoid and Sonovue, were employed with similar sensitivity (p > 0.05). CONCLUSION: These outcomes suggest the superiority of the CE-IOUS over MDCT, MRI, and IOUS for the staging of patients with CRLMs undergoing surgery. However, they should be treated with caution given the small number of the included studies.

Ulcerative Colitis in Hematological Malignancies: Paraneoplastic Manifestation or Coincidental Bystander?

Evidence of coexistence of diverse hematological malignancies-lymphoma, leukemia, multiple myeloma, and myelodysplastic syndromes-and either ulcerative colitis or Crohn's disease can be found in the literature. However, a more "systemic" effort to reach further and examine the potential of either one as paraneoplastic manifestation has not been performed. Based on these, three cases of ulcerative colitis manifesting before, simultaneously, and after the onset of different hematological malignancies are presented and critically evaluated.

Consensus statement of the Hellenic and Cypriot Gastric Cancer Study Group on the diagnosis, staging and management of gastric cancer.

Gastric Cancer epidemics have changed over recent decades, declining in incidence, shifting from distal to proximal location, transforming from intestinal to diffuse histology. Novel chemotherapeutic agents combined with modern surgical operations hardly changed overall disease related survival. This may be attributed to a substantial inherent geographical variation of disease genetics, but also to a failure to standardize and implement treatment protocols in clinical practice. To overcome these drawbacks in Greece and Cyprus, a Gastric Cancer Study Group under the auspices of the Hellenic Society of Medical Oncology (HeSMO) and Gastrointestinal Cancer Study Group (GIC-SG) merged their efforts to produce a consensus considering ethnic parameters of healthcare system and the international proposals as well. Utilizing structured meetings of experts, a consensus was reached. To achieve further consensus, statements were subjected to the Delphi methodology by invited multidisciplinary national and international experts. Sentences were considered of high or low consensus if they were voted by ≥ 80%, or < 80%, respectively; those obtaining a low consensus level after both voting rounds were rejected. Forty-five statements were developed and voted by 71 experts. The median rate of abstention per statement was 9.9% (range: 0-53.5%). At the end of the process, one statement was rejected, another revised, and all the remaining achieved a high consensus. Forty-four recommendations covering all aspects of the management of gastric cancer and concise treatment algorithms are proposed by the Hellenic and Cypriot Gastric Cancer Study Group. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and individualization are emphasized.

Hyperuricemia and acute gout after laparoscopic sleeve gastrectomy.

The aim of this study was to evaluate the prevalence of hyperuricemia and acute gout after laparoscopic sleeve gastrectomy (LSG). Risk factors for developing gout were also examined. Eighty-five patients underwent LSG were enrolled in this prospective study. Serum uric acid levels, gout attacks and total water levels % derived by bioimpedance were examined pre-operatively and 1 month post-operatively. Hyperuricemia was identified in 30.6% pre-operatively and in 18.82% of patients post-operatively. From the patients' group with pre-operative hyperuricemia, 53.9% were normalized, 46.2% had increased uric acid post-operatively while gout was observed in 11.5%. From the patients group without pre-operative hyperuricemia, hyperuricemia and gout were observed in 6.8% and 5.1% post-operatively, respectively. The relative risk for developing hyperuricemia was 6.2 (95% confidence interval [CI] 2.2-17.8) and for developing gout was 2.3 (95% CI 2.2-17.8). Statistical significant differences for gout among the groups with and without gout were indicated concerning pre-operative use of medications (P < 0.001), age (P = 0.025), post-operative uric acid levels (P < 0.001) and post-operative total water levels % (P = 0.048). The prevalence of hyperuricemia was 18.8% and gout attack of 7.1% 1 month after LSG. From the cohort of patients with pre-operative hyperuricemia, a significant proportion normalized uric acid, while 11.5% developed gout. Patients without hyperuricemia pre-operatively developed hyperuricemia and gout in 6.8% and 5.1% post-operatively, respectively. The patients who had gout were younger and had 37% water levels post-operatively.

Validation of the suter questionnaire after laparoscopic sleeve gastrectomy in the Greek population.

BACKGROUND & AIMS: The purpose of this study was to validate the Greek version of Suter questionnaire in order to be used for the evaluation of patients after Laparoscopic Sleeve Gastrectomy (LSG). METHODS: A total of 170 patients were enrolled in the study. RESULTS: The correlation coefficients for criterion validity had range between 0.202 (Food Tolerance) and 0.252 (Suter Total Score) (p < 0.05).There was moderate correlation between the questionnaire's subscales and the Hematocrit which satisfied the criterion validity marginally. The internal consistency measured with Cronbach's alpha yielded a value of 0.866 for the factor tolerance and 0.78 for the factor symptoms, which indicate excellent internal consistency. Excellent test-retest reliability with ICC of 0.997 for food tolerance and 0.990 for symptoms were also observed. The Suter questionnaire demonstrated a high sensitivity to detect clinical changes. CONCLUSION: The Greek version of Suter questionnaire seemed to be valid and reliable to assess morbidly obese patients after LSG.

Laparoscopic Gastric Plication versus Laparoscopic Sleeve Gastrectomy: An Up-to-Date Systematic Review and Meta-Analysis.

Introduction: A meta-analysis was conducted in order to provide an up-to-date comparison of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric plication (LGP) for morbid obesity. Materials and Methods: The PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were used for the conduction of this study. A systematic literature search was performed in the electronic databases (MEDLINE, CENTRAL, and Web of Science and Scopus). The fixed effects or random effects model was used according to the Cochran Q test. Results: Totally, 12 eligible studies were extracted. LSG displayed a statistically significant lower rate of overall complications (OR: 0.35; 95% CI: 0.17, 0.68; p=0.002) and a sustainable higher %EWL through all time endpoints (OR: 4.86, p=0.04; OR: 7.57, p < 0.00001; and OR: 13.74; p < 0.00001). There was no difference between the two techniques in terms of length of hospital stay (p=0.16), operative duration (p=0.81), reoperation rate (p=0.51), and cost (p=0.06). Conclusions: LSG was demonstrated to have a lower overall complications and a higher weight loss rate, when compared to LGP. Further RCTs of a higher methodological quality level, with a larger sample size, are required in order to validate these findings.

Hair Loss After Laparoscopic Sleeve Gastrectomy.

AIM: The aim of this study was to evaluate the prevalence of hair loss after laparoscopic sleeve gastrectomy (LSG). The effects of variables on the likelihood that patients developed hair loss were also examined. MATERIAL AND METHODS: Fifty patients who underwent LSG were enrolled in this prospective study. Demographics, hematocrit, iron, zinc, folic acid, vitamin B12, total proteins, and albumin were evaluated preoperatively and 6 months postoperatively. RESULTS: Hair loss was observed in 56% of patients and particularly in 46% in females and in 10% in males. Analysis of variance indicated statistical differences for hair loss among the groups with and without hair loss concerning preoperative zinc (p < 0.001), postoperative zinc (p < 0.001), preoperative B12 (p < 0.001), postoperative B12 (p < 0.001), postoperative folic acid (p = 0.039), and postoperative use of supplements (p < 0.001). Patients with hair loss had lower values of zinc preoperatively and postoperatively compared to patients without hair loss (0.61 vs 0.81 mcg/ml) (0.46 vs 0.73 mcg/ml) and also lower values of vitamin B12 preoperatively and postoperatively compared to patients without hair loss (243.04 vs 337.41 pg/ml) (261.54 vs 325.68 pg/ml). Interestingly, the zinc levels were normal preoperatively and lower to normal levels postoperatively and the levels of vitamin B12 were lower than normal values preoperatively in patients with hair loss. Patients with hair loss had mean lower levels of postoperative folic acid of 8 ng/ml. CONCLUSION: The prevalence of hair loss was 56% 6 months after LSG. Preoperative monitoring and counseling of these micronutrients may be a preventive and therapeutic measure.

A meta-analysis of laparoscopic versus open left lateral hepatic sectionectomy.

BACKGROUND: This study aimed to assess the perioperative outcomes of laparoscopic left lateral sectionectomy (LLLS) compared with an open (OLLS) approach. METHOD: A systematic literature search was performed in PubMed, Scopus and Cochrane library, in accordance with the PRISMA guidelines. The Odds Ratio (ORs), the weighted mean difference (WMD) and 95% confidence interval (95% CI) were evaluated, by means of Random-Effects model. RESULTS: Ten articles met the inclusion criteria and incorporated 2640 patients. This study reveals comparable mean operative time, mean operative margin size and rate of R1 resection between LLLS and OLLS. The intraoperative mean blood loss, mean length of ICU stay, mean hospital stay were significantly increased in the OLLS group (p < 0.05). Complications were assessed according to the Clavien-Dindo classification. The incidence of grade I-II complications was similar between the two groups. The incidence of grade III-V complications was increased in the OLLS group (p = 0.008). The mean perioperative cost was similar between the two techniques. CONCLUSION: These outcomes for left lateral sectionectomy suggest that both approaches are feasible and safe. However, the results should be treated with caution given the small number of the included randomized controlled studies and potential for selection bias between the two techniques.