Laparoscopic total fundoplication is superior to medical treatment for reducing the cancer risk in Barrett's esophagus: a long-term analysis.

The present study aims to compare the effectiveness of surgical and medical therapy in reducing the risk of cancer in Barrett's esophagus in a long-term evaluation. A prospective cohort was designed that compared Barrett's esophagus patients submitted to medical treatment with omeprazole or laparoscopic Nissen fundoplication. The groups were compared using propensity score matching paired by Barrett's esophagus length. A total of 398 patients met inclusion criteria. There were 207 patients in the omeprazole group (Group A) and 191 in the total fundoplication group (Group B). After applying the propensity score matching paired by Barrett's esophagus length, the groups were 180 (Group A) and 190 (Group B). Median follow-up was 80 months. Group B was significantly superior for controlling GERD symptoms. Group B was more efficient than Group A in promoting Barrett's esophagus regression or blocking its progression. Group B was more efficient than Group A in preventing the development of dysplasia and cancer. Logistic regression was performed for the outcomes of adenocarcinoma and dysplasia. Age and body mass index were used as covariates in the logistic regression models. Even after regression analysis, Group B was still superior to Group A to prevent esophageal adenocarcinoma or dysplasia transformation (odds ratio [OR]: 0.51; 95% confidence interval [CI]: 0.27-0.97, for adenocarcinoma or any dysplasia; and OR: 0.26; 95% CI: 0.08-0.81, for adenocarcinoma or high-grade dysplasia). Surgical treatment is superior to medical management, allowing for better symptom control, less need for reflux medication use, higher regression rate of the columnar epithelium and intestinal metaplasia, and lower risk for progression to dysplasia and cancer.

Electrical nerve stimulation therapy in refractory primary monosymtomatic enuresis - A sistematic review.

OBJECTIVE: To analyze the effect of electrical nerve stimulation on urinary symptoms in pediatric patients with monosymptomatic primary enuresis refractory to conventional treatment. METHODS: Three databases (Medline, Embase, and Cochrane) were searched and 160 studies were identified by July 15, 2020. After establishing and applying the inclusion and exclusion criteria, a step-by-step analysis was performed using the title, abstract and full text. The Cochrane Collaboration Tool was then used to analyze the biases of the selected studies. RESULTS: Of the 160 articles found, 03 were selected for this systematic review. In 02 studies there was a significant reduction in the number of wet nights/week after electrical nerve stimulation. Urodynamic pattern was evaluated in 01 study, with improvement of maximum cystometric capacity in the intervention group. About maximum voided volume, there was no improvement in 01 study, but in other, there was increase in the intervention group. CONCLUSION: Electrical nerve stimulation might promote improvement in partial and total response scores over the number of dry nights, with no improvement in urodynamic parameters, and could be considered as an feasible option in the management of refractory monosymptomatic primary enuresis. However, it is worth emphasizing the need to conduct more RCTs with a larger sample for better evaluation of the role of neurostimulation.

Laparoscopic treatment of giant hiatal hernia with or without mesh reinforcement: A systematic review and meta-analysis.

BACKGROUND: The use of mesh associated with cruroplasty is still controversial, especially in cases of giant hernias, due to possible complications of the prosthesis reported in the literature, such as infection, chest migration, shrinkage, esophageal and aortic erosion, stenosis and obstruction. This systematic review and meta-analysis aimed to compare the use or not of mesh as a reinforcement in the laparoscopic repair of giant hernias and to determine which technique has the best results in recurrence and complication rates. MATERIAL AND METHODS: A search was conducted using databases and included prospective and randomized studies. The studies should include patients with giant hernias who have undergone laparoscopic treatment comparatively analyzed between cruroplasty and suture associated with prosthetic reinforcement. RESULTS: Of the 768 articles analyzed, 8 were selected for systematic review, and 7 were included in the meta-analysis (3 randomized trials with higher evidence strength, 2 randomized trials with lower methodological quality, and 2 prospective cohorts). The meta-analysis showed no statistically significant differences in favor of any of the intervention methods (mesh versus suture cruroplasty) for the different outcomes evaluated: recurrence (RD -0.06, CI [-0.13,0.01], I2 22%, p 0.27); postoperative complications (RD 0.04, CI [-0.01,0.9], I2 5%, p 0.30); deaths (RD -0.01, CI [-0.04, 0.02], I2 0%, p 74); intraoperative complications (RD -0.03, CI [-0.07, 0.1]); reoperation (RD -0.04, CI [-0.10, 0.02], p 0.14). CONCLUSION: There is no evidence supporting that routine mesh reinforcement in laparoscopic repair of giant hernias decreases recurrence and other complications. Systematic review registration number at PROSPERO: CRD42019147468.

Neoadjuvant therapy or upfront surgery? A systematic review and meta-analysis of T2N0 esophageal cancer treatment options.

BACKGROUND: Esophageal carcinoma usually shows poor long-term survival rates, even when esophagectomy, the standard curative treatment is performed. As a result, there has been increasing interest in the neoadjuvant therapy, which could potentially downstage cancer, eliminate micrometastasis and ergo increase resectability and curative (R0) resection. Currently, for the earliest stage esophageal cancers, most guidelines point out to the role of endoscopic treatment, and for T1bN0 upfront surgery. For locally advanced cases, several studies have demonstrated the benefits of neoadjuvant therapy to increase resectability. For clinical stage T2N0 esophageal cancer, there is no consensus as to the optimal treatment strategy. METHODS: A systematic review and meta-analysis was performed to compare neoadjuvant therapy with surgery alone on clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence, post-operative mortality, anastomotic leak, and R0 resection rate. RESULTS: For overall survival at the mean follow-up point, the neoadjuvant therapy was not associated to a higher probability of survival than upfront surgery in cT2N0 patients (risk difference: 0.00; 95% CI: -0.09, 0.09). There was no difference between neoadjuvant therapy and primary surgery concerning recurrence (risk difference: 0.21; 95% CI: -0.03, 0.45); perioperative mortality (risk difference: 0.00; 95% CI: -0.02, 0.01); and risk for anastomotic leak (risk difference: -0.08; 95% CI: -0.21, 0.05). Pooled data showed that neoadjuvant therapy was associated to a higher risk for positive margins after resection (risk difference: 0.04; 95% CI: 0.02, 0.06). CONCLUSIONS: This review showed that neoadjuvant therapy is not associated to better results than surgery alone, for the management of clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence rate, perioperative mortality, anastomotic leak, and seems to be associated to a higher risk for resection with positive margins.

Esophageal achalasia: a risk factor for carcinoma. A systematic review and meta-analysis.

Achalasia of the cardia is associated with an increased risk of esophageal carcinoma. The real burden of achalasia at the malignancy genesis is still a controversial issue. Therefore, there are no generally accepted recommendations on follow-up evaluation for achalasia patients. This study aims to estimate the risk of esophageal adenocarcinoma and squamous cell carcinoma in achalasia patients. We searched for association between carcinoma and esophageal achalasia in databases up to January 2017 to perform a systematic review and meta-analysis. A total of 1,046 studies were identified from search strategy, of which 40 were selected for meta-analysis. A cumulative number of 11,978 esophageal achalasia patients were evaluated. The incidence of squamous cell carcinoma was 312.4 (StDev 429.16) cases per 100,000 patient-years at risk. The incidence of adenocarcinoma was 21.23 (StDev 31.6) cases per 100,000 patient-years at risk. The prevalence for esophageal carcinoma was 28 carcinoma cases in 1,000 esophageal achalasia patients (CI 95% 2, 39). The prevalence for squamous cell carcinoma was 26 cases in 1,000 achalasia patients (CI 95% 18, 39) and for adenocarcinoma was 4 cases in 1,000 achalasia patients (CI 95% 3, 6).The absolute risk increase for squamous cell carcinoma was 308.1 and for adenocarcinoma was 18.03 cases per 100,000 patients per year. To the best of our knowledge, this is the first meta-analysis estimating the burden of achalasia as an esophageal cancer risk factor. The high increased risk rate for cancer in achalasia patients points to a strict endoscopic surveillance for these patients. Also, the increased risk for developing adenocarcinoma in achalasia patients suggests fundoplication after myotomy, to avoid esophageal reflux and Barret esophagus, a known risk factor for adenocarcinoma.