A critical review of the safety of minimally invasive surgery in the era of COVID-19.

BACKGROUND: The Corona virus disease 2019 (COVID-19) pandemic has affected surgical practice around the world. While several abdominal emergencies can be managed effectively and safely using minimally invasive surgery (MIS), the safety of using MIS amid the COVID-19 pandemic has been debated. MIS, including laparoscopy and robotic surgery, is considered an aerosol-generating procedure and some recent research demonstrated possible spread of the virus through aerosol. This review assessed the available evidence on the safety of MIS in the COVID-19 era, explored the possible precautions to be taken when using MIS to prevent exposure of the operating team to infection, and highlighted the recommendations of several surgical societies in this regard. MATERIAL AND METHODS: Electronic databases, Google Scholar, and pre-print archives were searched for evidence on airborne transmission of COVID-19 and the safety of MIS amid the COVID-19 pandemic. Recommendations of recognized surgical societies were also searched. The available evidence was summarized in a narrative manner. RESULTS: Limited data on the possibility of airborne transmission of COVID-19 were found. The studies that reported on the presence of the SARS-COV-2 in the air samples of patients with COVID-19 had conflicting results. Several precautions to minimize the presumed risk of exposure of the operation room staff to COVID-19 were devised. CONCLUSION: According to the available evidence and recommendations of different surgical societies, MIS may be used in the treatment of acute abdominal emergency. However, considerable caution should be taken to avoid the presumed risk of aerosolization of the virus particles during the procedure, which may expose the operating staff to the risk of COVID-19.

Prognostic Significance of Lymphocyte-to-Monocyte and Platelet-to-Lymphocyte Ratio in Rectal Cancer: A Systematic Review, Meta-analysis, and Meta-regression.

BACKGROUND: The low lymphocyte-to-monocyte ratio and high platelet-to-lymphocyte ratio have been reported to be poor prognostic indicators in various solid tumors, but the prognostic significance in rectal cancer remains controversial. OBJECTIVES: We sought to determine the prognostic value of the lymphocyte-to-monocyte ratio and the platelet-to-lymphocyte ratio following curative-intent surgery for rectal cancer. DATA SOURCES: Following PRISMA guidelines (PROSPERO, ID: CRD42020190880), PubMed and Embase databases were searched through January 2021 including 3 other registered medical databases. STUDY SELECTION: Studies evaluating the impact of pretreatment lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio on overall or disease-free survival in patients undergoing curative rectal cancer resection were selected. MAIN OUTCOMES MEASURES: The main outcome measures were overall and disease-free survival. RESULTS: A total of 23 studies (6683 patients) were included; lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio were evaluated in 14 and 16 studies. A low lymphocyte-to-monocyte ratio was associated with poorer overall survival (HR, 1.57; 95% CI, 1.29-1.90; p < 0.001) and disease-free survival (HR, 1.29; 95% CI, 1.13-1.46; p < 0.001). However, when the analysis was limited to patients treated with surgery alone or to those with stage I to III tumors, lymphocyte-to-monocyte ratio was not a predictor of overall survival and disease-free survival. The platelet-to-lymphocyte ratio did not predict for overall or disease-free survival, regardless of the treatment modality, studied population, tumor stage, or cutoff value. Finally, a low lymphocyte-to-monocyte ratio, but not a high platelet-to-lymphocyte ratio, was inversely correlated with complete pathologic response rate. LIMITATIONS: The retrospective nature of most included studies was a limitation. CONCLUSIONS: Pretreatment lymphocyte-to-monocyte ratio, but not platelet-to-lymphocyte ratio, correlates with tumor response to neoadjuvant chemoradiotherapy and poorer prognosis after curative-intent surgery for rectal cancer, and it potentially represents a simple and reliable biomarker that could help optimize individualized clinical decision-making in high-risk patients. REGISTRATION: https://www.crd.york.ac.uk/prospero/; ID: CRD42020190880.

Prognostic and predictive value of neutrophil-to-lymphocyte ratio after curative rectal cancer resection: A systematic review and meta-analysis.

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with poor prognosis in numerous solid malignancies. Here, we quantify the prognostic value of NLR in rectal cancer patients undergoing curative-intent surgery, and compare it with platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR). METHODS: A comprehensive search of several electronic databases was performed through January 2021, to identify studies evaluating the prognostic impact of pretreatment NLR in patients undergoing curative rectal cancer resection. The endpoints were overall survival (OS), disease-free survival (DFS), and clinicopathologic parameters. The pooled hazard ratio (HR) or odds ratio with 95% confidence interval (CI) were calculated. RESULTS: Thirty-one studies comprising 7553 patients were assessed. All studies evaluated NLR; thirteen and six evaluated PLR and LMR, respectively. High NLR was associated with worse OS (HR 1.92, 95% CI 1.60-2.30, P < 0.001) and DFS (HR 1.83, 95% CI 1.51-2.22, P < 0.001), and the results were consistent in all subgroup analyses by treatment modality, tumor stage, study location, and NLR cut-off value, except for the subgroups limited to cohorts with cut-off value ≥ 4. The size of effect of NLR on OS and DFS was greater than that of PLR, and similar to that of LMR. Finally, high NLR was associated with lower rate of pathologic complete response. CONCLUSIONS: In the setting of curative rectal cancer resection, pretreatment NLR correlates with tumor response to neoadjuvant therapy, and along with LMR, is a robust predictor of poorer prognosis. These biomarkers may thus help risk-stratify patients for individualized treatments and enhanced surveillance.

Rate of Application and Outcome of Non-operative Management of Acute Appendicitis in the Setting of COVID-19: Systematic Review and Meta-analysis.

BACKGROUND: Non-operative management (NOM) of acute appendicitis has been assessed in several studies before COVID-19 pandemic. This systematic review aimed to assess the extent of adoption, efficacy, and safety of NOM of acute appendicitis in the setting of COVID-19. METHODS: This was a PRISMA-compliant systematic review of the literature. Electronic databases and Google Scholar were queried for studies that applied NOM of acute appendicitis during COVID-19. The main outcome measures were the rates of NOM application during the pandemic as compared to the pre-pandemic period, failure and complication rates of NOM. Failure was defined as the need for appendectomy during NOM and complications included development of appendicular mass or abscess. RESULTS: Fourteen studies (2140 patients) were included. The male to female ratio was 1.44:1 and median age was 34. Nine hundred fifty-nine (44.8%) patients had a trial of NOM. The weighted mean rate of NOM application was 50.1% (95%CI: 29.8-70.5%). The application of NOM during the pandemic was significantly more likely than its application before COVID-19 (OR = 6.7, p < 0.001). The weight mean failure rate of NOM was 16.4% (95%CI: 9.4-23.4). NOM failure was more likely in children and patients with complicated appendicitis. The weighted mean complication rate after NOM was 4.5% (95%CI: 1.4-7.7). NOM had significantly lower odds for complications than appendectomy (OR = 0.36, p = 0.03). There was no mortality after application of NOM. CONCLUSION: NOM of acute appendicitis in the setting of COVID-19 may be a safe, short-term alternative to surgery with acceptably low failure and complication rates.

Efficacy and Safety Profile of Rectus Sheath Block in Adult Laparoscopic Surgery: A Meta-analysis.

BACKGROUND: Rectus sheath block (RSB) has been increasingly used for pain management after laparoscopic procedures but with a conflicting data on its analgesic efficacy. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of RSB in adults undergoing laparoscopic surgery. METHODS: A systematic literature search of the PubMed, Embase, CINAHL, and Cochrane Library databases was conducted from inception through October 1, 2020, to identify trials comparing RSB with a control group in laparoscopic surgery. The primary outcome was rest pain scores at 0-2 h postoperatively. Secondary outcomes included pain scores at rest at 10-12 and 24 h postoperatively, pain scores on movement at 0-2, 10-12, and 24 h postoperatively, 24- and 48-h opioid consumption, opioid-related side effects, and RSB-associated adverse events. RESULTS: Nine trials with 698 patients were included. RSB was associated with significantly lower rest pain scores at 0-2 h postoperatively (standardized mean difference -1.83, 95% confidence interval [-2.70, -0.96], P < 0.001, I2 = 95%) than control. Furthermore, RSB significantly reduced pain scores at rest at 10-12 h postoperatively and on movement at 0-2 h postoperatively, 24-h opioid consumption, and opioid-related side effects. Other secondary outcomes were similar between groups. Preoperative RSB provided better pain control compared with postoperative block administration. None of the studies reported local or systemic complications related to RSB. CONCLUSIONS: In the setting of laparoscopic surgery, RSB improves pain control for up to 12 h postoperatively and reduces opioid consumption, without major reported adverse events.

Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis.

OBJECTIVE: Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES). METHODS: A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated. RESULTS: The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93-100%) I2 = 34%, 82% (69-93%) I2 = 58%, and 32% (17-49%), I2 = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97-100%) I2 = 19%, 93% (85-98%) I2 = 30%, and 15% (7-25%), I2 = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low. CONCLUSIONS: In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Transversus abdominis plane block versus thoracic epidural analgesia in colorectal surgery: a systematic review and meta-analysis.

BACKGROUND: The efficacy of transversus abdominis plane (TAP) block compared with thoracic epidural analgesia (TEA) in abdominal surgery has been controversial. We conducted this systematic review and meta-analysis to assess outcomes of TAP block and TEA in a procedure-specific manner in colorectal surgery. METHODS: A systematic literature search of the PubMed, Embase, Cochrane Library, and Scopus databases was conducted through July 10, 2020, to identify randomized controlled trials (RCTs) comparing TAP block with TEA in colorectal surgery. Primary outcomes were pain scores at rest and movement at 24 h postoperatively. Secondary outcomes included postoperative pain scores at 0-2 and 48 h, opioid consumption, postoperative nausea and vomiting (PONV), functional recovery, hospital stay, and adverse events. RESULTS: Six RCTs with 568 patients were included. Methodological quality of these RCTs ranged from moderate to high. TAP block provided comparable pain control, lower 24 h and total opioid consumption, shorter time to ambulation and urinary catheter time, and lower incidence of sensory disturbance and postoperative hypotension compared with TEA. Meanwhile, the 48-h opioid consumption, PONV incidence, and hospital stay were similar between groups. When laparoscopic surgery was the only surgical approach employed, TAP block provided additional benefits of shorter time to first flatus and lower incidence of PONV compared with TEA. CONCLUSIONS: Perhaps more germane to minimally invasive procedures, TAP block is equivalent to TEA in terms of postoperative pain control and provides better functional recovery with lower incidence of adverse events in patients undergoing colorectal surgery.

Late biliary endoclip migration after laparoscopic cholecystectomy: Case report and literature review.

INTRODUCTION: Although formerly considered a rarity, biliary endoclip-related complications are being diagnosed with increasing frequencies. Among these, migration of endoclip into the common bile duct (CBD) is a rare encounter that usually presents in the first two years after surgery. PRESENTATION OF CASE: This case demonstrates a late biliary endoclip migration after laparoscopic cholecystectomy. DISCUSSION: An 82-year-old male patient, with a history of laparoscopic cholecystectomy 22 years ago, presented with two-day history of severe upper abdominal pain. Routine hemogram and serum chemistry were remarkable for slightly raised alanine aminotransferase and C-reactive protein. A computed tomographic (CT) scan demonstrated a new metallic density within the CBD when compared to a previous CT scan 14 months earlier. An endoscopic retrograde cholangiography confirmed a metal endoclip within the mid-CBD contained within a choledochal stone. Balloon extraction of the endoclip and stone was successfully performed. The patient was discharged 2 days later, and remained symptom free for 1 year. CONCLUSION: To our knowledge, a latency of 22 years between cholecystectomy and clip migration has never been reported before. In cases of post-cholecystectomy abdominal pain the awareness of the surgeon should always be drawn to a clinical suspicion of endoclip migration into the CBD that can be easily remedied. Endoscopic biliary sphincterotomy with endoclip/stone removal is the therapeutic procedure of choice which usually circumvents the need for surgical extraction.

Transversus abdominis plane block using a short-acting local anesthetic reduces pain and opioid consumption after laparoscopic bariatric surgery: a meta-analysis.

BACKGROUND: Transversus abdominis plane (TAP) block is a form of regional anesthesia that has been increasingly employed in minimally invasive surgery. The data regarding its use in laparoscopic bariatric surgery, however, are still limited and at times controversial. OBJECTIVES: The aim of this meta-analysis was to assess the efficacy of TAP block after laparoscopic bariatric surgery. SETTING: Soba University Hospital, Sudan. MATERIALS: A systematic search was conducted through the Embase, Cochrane Collaboration, and PubMed databases for randomized controlled trials evaluating the effects of TAP block in patients undergoing laparoscopic bariatric surgery. Meta-analysis was performed using a random effects model. Primary endpoints were late (24 hr) pain scores at rest and on movement. Secondary endpoints included early (0-3 hr) pain scores at rest and on movement, opioid consumption, time to ambulation, length of hospital stay, and adverse events. RESULTS: Ten randomized controlled trials met our inclusion criteria, with 404 patients in the TAP block groups and 413 patients in the control groups. TAP block was associated with significantly improved late pain scores (at rest, standardized mean difference [SMD] -.95, P < .001; on movement, SMD -1.04, P = .01) and early pain scores (at rest, SMD -1.81, P < .001; on movement, SMD -1.80, P < .001), reduced postoperative opioid consumption at 24 hours (SMD -2.23 mg intravenous morphine, P < .001), a shorter time to ambulation (SMD -1.07 hours, P < .001), and reduced incidence of postoperative nausea and vomiting (OR .20, P = .01). No significant difference was noted regarding length of hospital stay (P = .70). Postoperative TAP block administration resulted in greater effects on opioid consumption at 24 hours compared with preoperative block administration. Finally, none of the studies reported any adverse effect of local anesthetic. CONCLUSION: Given the significant effect on early and late postoperative pain, opioid consumption, and postoperative recovery and the low risk profile, TAP block using a short-acting anesthetic should be encouraged in routine practice in patients undergoing laparoscopic bariatric surgery.

Laparoscopic-Guided Transversus Abdominis Plane Block for Postoperative Pain Management in Minimally Invasive Surgery: Systematic Review and Meta-Analysis.

BACKGROUND: Optimal postoperative pain therapy for patients undergoing minimally invasive surgery remains controversial. The aim of this meta-analysis was to compare the efficacy and safety of the novel laparoscopic-guided transversus abdominis plane block (L-TAP) with other analgesic alternatives in adults undergoing minimally invasive surgery. STUDY DESIGN: A systematic literature search of several databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines through March 9, 2020, to identify randomized controlled trials (RCTs) reporting on L-TAP. Primary outcomes were pain scores at rest and movement at 24 hours postoperatively. Secondary outcomes included postoperative pain scores at 0 to 4 and 48 hours, opioid consumption, hospital stay, functional recovery, patient satisfaction, and adverse events. RESULTS: Nineteen RCTs with 1,983 patients were included. All trials compared L-TAP with ultrasound-guided transversus abdominis plane block (US-TAP), local infiltration analgesia (LIA), or inactive control; none controlled for epidural analgesia. Methodologic quality of these RCTs ranged from moderate to high. L-TAP provided comparable pain control compared with US-TAP, and better early pain control compared with LIA. Recovery parameters, 24-hour opioid consumption, and postoperative nausea and vomiting (PONV) were comparable between L-TAP and US-TAP. Meanwhile, 24-hour opioid consumption, PONV incidence, hospital stay, and patient satisfaction favored L-TAP compared with LIA. None of the studies reported adverse events related to the L-TAP procedure. CONCLUSIONS: L-TAP is safe, and superior to LIA with respect to early pain control, opioid consumption, and patient satisfaction in adults undergoing minimally invasive surgery. Given its equivalence to US-TAP, L-TAP can be used as a safer and pragmatic alternative to epidural analgesia in this patient population.