Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer.

OBJECTIVES: To evaluate comparative outcomes of transanal total mesorectal excision (TaTME) and laparoscopic TME (LaTME) in patients with rectal cancer. METHODS: We systematically searched multiple databases and bibliographic reference lists. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits were applied. Overall intraoperative complications, overall postoperative complications, anastomotic leak, surgical site infections (SSIs), completeness of mesorectal excision, R0 resection, distal (DRM) and circumferential resection margin (CRM), number of harvested lymph nodes, and procedure time were the evaluated outcome parameters. RESULTS: We identified 18 comparative studies reporting a total of 2048 patients evaluating outcomes of TaTME (n = 1000) and LaTME (n = 1048) in patients with rectal cancer. TaTME was associated with significantly higher number of R0 resection (OR 1.67, P = 0.01) and harvested lymph nodes (MD 1.08, P = 0.01), and lower rate of positive CRM (OR 0.67, P = 0.04) and conversion to an open procedure (OR 0.17, P < 0.00001) compared with LaTME. However, there was no significant difference in intraoperative complications (OR 1.18, P = 0.54), postoperative complications (OR 0.89, P = 0.24), anastomotic leak (OR 0.88, P = 0.42), SSIs (OR 0.64, P = 0.26), completeness of mesorectal excision (OR 1.43, P = 0.19), DRM (MD 1.87, P = 0.16), CRM (MD 0.36, P = 0.58), and procedure time (MD - 10.87, P = 0.18) between TaTME and LaTME. Moreover, for low rectal tumours, TaTME was associated with significantly lower rate of anastomotic leak and higher number of lymph nodes (MD 2.06, P = 0.002). CONCLUSIONS: Although the meta-analysis of best available evidence (level 2) demonstrated that TaTME may be associated with better short-term oncological outcomes and similar clinical outcomes compared with LaTME, the differences between the two groups were small questioning their clinical relevance. No solid conclusions can be made due to lack of high quality randomised studies.

Meta-analysis and trial sequential analysis of robotic versus laparoscopic total mesorectal excision in management of rectal cancer.

BACKGROUND: We aimed to evaluate comparative outcomes of robotic and laparoscopic total mesorectal excision (TME) in patients with rectal cancer. METHODS: We systematically searched electronic data sources with application of combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Perioperative clinical and short-term oncological outcomes were evaluated. Trial Sequential Analysis of the outcomes was conducted. RESULTS: Nine randomised-controlled trials reporting 1463 patients evaluating outcomes of robotic TME (n = 728) and laparoscopic TME (n = 735) were included. Although the robotic approach was associated with significantly longer operative time (MD 31.64, P = 0.002), it was associated with significantly longer DRM (MD 0.8, P = 0.004) and shorter time to soft diet (MD - 0.50, P = 0.03) compared to the laparoscopic approach. Moreover, there was no significant difference in intraoperative (RR 1.07, P = 0.76)) and postoperative (RR 0.97, P = 0.81) complications, anastomotic leak (RR 0.93, P = 0.69), conversion to open rate (RR 0.46, P = 0.05), blood loss (MD 19.65, P = 0.74), time to first flatus (MD - 0.30, P = 0.37), LARS (RR 0.83, P = 0.41), ileus (RR 0.72, P = 0.39), positive CRM (RR 0.82, P = 0.49), PRM (MD - 0.5, P = 0.55), number of harvested lymph nodes (MD 0.33, P = 0.58), or length of stay (MD - 0.60, P = 0.12) between two groups. The Trial Sequential Analysis demonstrated that the risk of type 1 and type 2 errors was minimal in most outcomes. CONCLUSIONS: Moderate-quality evidence suggested that robotic and laparoscopic TME may be comparable in terms of clinical and short-term oncological profile but the robotic approach may be associated with longer procedure time. Future high-quality randomised studies are encouraged to compare the functional, long-term oncological, and cost-effectiveness outcomes of both approaches.

Meta-analysis of medial-to-lateral versus lateral-to-medial colorectal mobilisation during laparoscopic colorectal surgery.

OBJECTIVES: To evaluate comparative outcomes of medial-to-lateral and lateral-to-medial colorectal mobilisation in patients undergoing laparoscopic colorectal surgery. METHODS: We conducted a systematic search of electronic databases and bibliographic reference lists. Perioperative mortality and morbidity, procedure time, length of hospital stay, rate of conversion to open procedure, and number of harvested lymph nodes were the outcome parameters. Combined overall effect sizes were calculated using fixed-effects or random-effects models. RESULTS: We identified eight comparative studies reporting a total of 1477 patients evaluating outcomes of medial-to-lateral (n = 626) and lateral-to-medial (n = 851) approaches in laparoscopic colorectal resection. The medial-to-lateral approach was associated with significantly lower rate of conversion to open (odds ratio (OR) 0.43, P = 0.001), shorter procedure time (mean difference (MD) - 32.25, P = 0.003) and length of hospital stay (MD - 1.54, P = 0.02) compared to the lateral-to-medial approach. However, there was no significant difference in mortality (risk difference (RD) 0.00, P = 0.96), overall complications (OR 0.78, P = 0.11), wound infection (OR 0.84, P = 0.60), anastomotic leak (OR 0.70, P = 0.26), bleeding (OR 0.60, P = 0.50), and number of harvested lymph nodes (MD - 1.54, P = 0.02) between two groups. Sub-group analysis demonstrated that the lateral-to-medial approach may harvest more lymph nodes in left-sided colectomy (MD - 1.29, P = 0.0009). The sensitivity analysis showed that overall complications were lower in the medial-to-lateral group (OR 0.72, P = 0.49). CONCLUSIONS: Our meta-analysis (level 2 evidence) showed that medial-to-lateral approach during laparoscopic colorectal resection may reduce procedure time, length of hospital stay and conversion to open procedure rate. Moreover, it may probably reduce overall perioperative morbidity. However, both approaches carry similar risk of mortality, and have comparable ability to harvest lymph nodes. Future high-quality randomised trials are required.

Laparoscopic Transcystic Versus Transductal Common Bile Duct Exploration: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate comparative outcomes of laparoscopic transcystic (TC) and transductal (TD) common bile duct (CBD) exploration. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. CBD clearance rate, perioperative complications, and biliary complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, conversion to open procedure were the secondary outcomes. Combined overall effect sizes were calculated using random-effects models. RESULTS: We identified 30 studies reporting a total of 4073 patients comparing outcomes of laparoscopic TC (n = 2176) and TD (N = 1897) CBD exploration. The TC approach was associated with significantly lower overall complications (RD: -0.07, P = 0.001), biliary complications (RD: -0.05, P = 0.0003), and blood loss (MD: -16.20, P = 0.02) compared to TD approach. Moreover, the TC approach significantly reduced the length of hospital stay (MD: -2.62, P < 0.00001) and procedure time (MD: -12.73, P = 0.005). However, there was no significant difference in rate of CBD clearance (RD: 0.00, P = 0.77) and conversion to open procedure (RD: 0.00, P = 0.86) between two groups. CONCLUSIONS: Laparoscopic TC CBD exploration is safe and reduces overall morbidity and biliary complications compared to the TD approach. Moreover, it is associated with significantly shorter length of hospital stay and procedure time. High-quality randomised trials may provide stronger evidence with respect to impact of the cystic duct/CBD diameter, number or size of CBD stones, or cystic duct anatomy on the comparative outcomes of TC and TD approaches.

Adult jejunojejunal intussusception after jejunoileal bypass bariatric surgery.

The jejunoileal bypass is one of the bariatric surgical options which have been abandoned for two reasons: first, it leads to severe malnutrition and liver failure and, second, the bypassed jejunum-being a blind loop-is susceptible to bacterial accumulation which might become a source of sepsis due to bacterial translocation. We hereby report a case of a 27-year-old lady who presented with jejunojejunal intussusception of the blind jejunal loop 2 years after jejunoileal bypass surgery. This complication could have led to serious consequences if it was not managed in the appropriate time.

Meta-analysis of laparoscopic groin hernia repair with or without mesh fixation.

OBJECTIVES: To evaluate comparative outcomes of laparoscopic repair of groin hernia with and without mesh fixation. METHODS: MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists were systematically checked. Combination of free text and controlled vocabulary search adapted were applied to thesaurus headings, search operators and limits in each of the above databases. Post-operative pain, procedure time, conversion rate, length of hospital stay, time taken to normal activities, overall complications, seroma formation, cost and recurrence were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. This protocol was registered at the International Prospective Register of Systematic Reviews (registration number: CRD42019139564). RESULTS: We identified 13 randomized controlled trials reporting a total of 1731 patients (2021 groin hernia) evaluating outcomes of laparoscopic hernia repair with mesh fixation using stapler or tacker (n = 853 patients, 999 hernia) and without mesh fixation (n = 878 patients, 1022 hernia). Mesh Fixation was associated with significantly higher post-operative pain assessed by visual analogue scale (VAS) (MD: 0.59; 95% CI, 0.05-1.13, P = 0.03) and longer procedure time (MD: 2.00; 95% CI, 0.98-3.02, P = 0.0001), compared to no fixation technique. However, there was no significant difference in length of hospital stay (MD:0.09; 95% CI, -0.05-0.23, P = 0.19), time to normal activities, (MD: 0.12; 95% CI, -0.37-0.61, P = 0.69), overall complications (OR: 1.05; 95% CI, 0.77-1.43, P = 0.76), seroma formation (OR: 0.63; 95% CI, 0.39-1.00, P = 0.05) and recurrence rate (RD: 0.00; 95% CI, -0.01-0.01, P = 0.84) between two groups. CONCLUSIONS: Avoiding mesh fixation with a stapler or tacker during laparoscopic groin hernia repair may reduce postoperative pain and procedure time. Future studies are encouraged to evaluate cost effectiveness of each approach.