A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis.

BACKGROUND: To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS: An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS: Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS: Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.

Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis.

PURPOSE: We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains. METHODS: A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4-7.1) and LNF (RR 2.5; Crl 1.3-4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate. CONCLUSION: LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments' efficacy and their outcomes is needed.

Prophylactic mesh reinforcement for midline incisional hernia prevention: systematic review and updated meta-analysis of randomized controlled trials.

BACKGROUND: Incisional hernia (IH) is a common complication after abdominal surgery. Prevention of IH is matter of intense research. Prophylactic mesh reinforcement (PMR) has been shown to be promising in the minimization of IH risk after elective midline laparotomy. METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PMR vs. primary suture closure (PSC). Risk ratio (RR) and standardized mean difference (MD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS: Fourteen RCTs (2332 patients) were included. Overall, 1280 (54.9%) underwent PMR while 1052 (45.1%) PSC. Postoperative follow-up ranged from 12 to 67 months. The incidence of IH was reduced for PMR vs. PSC (13.4% vs. 27.5%). The estimated pooled IH RR for PMR vs. PSC is 0.38 (95% CI 0.24-0.58; p < 0.001). Stratified subgroup analysis according to mesh location shows a risk reduction for intraperitoneal (RR = 0.65; 95% CI 0.48-0.89), preperitoneal (RR = 0.18; 95% CI 0.04-0.81), retromuscular (RR = 0.47; 95% CI 0.24-0.92) and onlay (RR = 0.24; 95% CI 0.12-0.51) compared to PSC. The seroma RR was higher for PMR (RR = 2.05; p = 0.0008). No differences were found for hematoma (RR = 1.49; p = 0.34), surgical site infection (SSI) (RR = 1.17; p = 0.38), operative time (OT) (MD = 0.27; p = 0.413), and hospital length of stay (HLOS) (MD = -0.03; p = 0.237). CONCLUSIONS: PMR seems effective in reducing the risk of IH after elective midline laparotomy compared to PSC in the medium-term follow-up. While the risk of postoperative seroma appears higher for PMR, hematoma, SSI, HLOS and OT seems comparable.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life.

BACKGROUND: Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression. OBJECTIVE: To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms. METHODS: Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used. RESULTS: Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved. CONCLUSIONS: LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Laparoscopic posterior cruroplasty: a patient tailored approach.

BACKGROUND: Different surgical variations have been described for laparoscopic crural repair however, the technique is not standardized and left to the surgeons' preference. OBJECTIVE: The purpose of this study is to describe a standardized "patient tailored" approach for laparoscopic posterior cruroplasty in the setting of elective hiatal hernia repair. METHODS: Retrospective single-center study was conducted (November 2015 to November 2019). The technical aspects of a standardized "patient tailored" laparoscopic posterior crural repair are described. Perioperative outcomes and patients' quality of life, measured with the disease specific Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and generic Short Form-36 (SF-36), were analyzed. RESULTS: One hundred and forty-one patients were treated for symptomatic hiatal hernia according to the described "patient tailored" concept. Overall, 102 (72.3%) patients underwent simple suture repair while simple suture repair buttressed with biosynthetic resorbable U shaped mesh [Phasix ST®-Bard] was used in 39 (27.7%) patients. Toupet fundoplication was fashioned in all patients. The median operative time was 131 min (IQR 55-240). No intraoperative complications or conversion to open surgery occurred. The median postoperative stay was 1.8 days (range 1-7). The overall postoperative complication rate was 4.2%. The median follow-up was 21 months (IQR range 1-34) with 102 patients having a minimum follow-up of 6 months. Recurrent hernia was diagnosed in three patients (2.1%), but none required reoperation. No mesh-related complications occurred. Compared to baseline, the median GERD-HRQL (p = 0.003) and all SF-36 items (p < 0.001) were significantly improved. CONCLUSION: The application of a standardized "patient tailored" concept for laparoscopic posterior cruroplasty seems safe and effective in the medium-term follow-up with promising perioperative outcomes and quality of life improvement. This approach may be valuable to assure procedure reproducibility, standardization, and to uniformly interpret the outcomes.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience.

BACKGROUND: Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus. OBJECTIVE: The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST®). METHODS: Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST® mesh and Toupet fundoplication. RESULTS: Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001). CONCLUSIONS: Laparoscopic crura augmentation with Phasix-ST® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

Open mesh vs. suture umbilical hernia repair: systematic review and updated trial sequential meta-analysis of randomized controlled trials.

PURPOSE: To examine the updated evidence on safety, effectiveness, and outcomes of mesh versus suture elective umbilical hernia (UH) repair and to explore the timely tendency variations favouring one treatment over another. METHODS: MEDLINE and CENTRAL databases were consulted. A systematic review, pairwise meta-analysis, and trial sequential analysis (TSA) were conducted. RESULTS: Six RCTs were included for a total of 742 patients. Overall, 383 (51.6%) underwent mesh, while 359 (48.4%) underwent suture repair. The estimated pooled postoperative recurrence RR was 0.27 (95% CI 0.13-0.53; p < 0.001). The TSA showed a statistically significant timely tendency in favour of mesh repair with a boundary cross curve (Z = 1.96) before reaching the information size. The estimated pooled seroma, haematoma, and wound infection RR were 1.45 (p = 0.368), 0.54 (p = 0.196), and 0.71 (p = 0.375), respectively. The TSA for wound-related complications showed partial, non-significant results. CONCLUSIONS: Elective UH mesh repair seems to be associated with reduced risk of postoperative recurrence compared to simple suture repair with a statistically significant timely trend endorsed by the TSA. Definitive considerations concerning the cumulative effect for seroma, haematoma, and wound infection are premature. Further studies are warranted to endorse these results and deeply investigate the timely tendency variations.

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis.

BACKGROUND: Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. METHODS: A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. RESULTS: Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87). CONCLUSIONS: This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.

Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis.

PURPOSE: To examine the current evidence on the therapeutic role and outcomes of robotic Transabdominal Preperitoneal Inguinal hernia repair (rTAPP) to better define its risk-benefit ratio and guide clinical decision-making. METHODS: PubMed, EMBASE, and Web of Science were consulted. A Frequentist single-arm study-level random effect meta-analysis was performed. RESULTS: Twelve studies published between 2015 and 2018 met the inclusion criteria (1645 patients). Patients' age ranged from 16 to 96, the BMI ranged from 19 to 35.6 kg/m2, and 86.1% were males. Unilateral hernia repair was performed in 69.6% while bilateral hernia repair was performed in 30.4% of patients. The operations were all conducted using the da Vinci Xi or Si robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). The rTAPP was successfully completed in 99.4% of patients and the operative time ranged from 45 to 180.4 min. The postoperative follow-up ranged from 16 to 368 days. The estimated pooled prevalence of intraoperative complications and conversion were 0.03% (95% CI 0.00-0.3) and 0.14% (95% CI 0.0-0.5%), respectively. The estimated pooled prevalence of urinary retention, seroma/hematoma, and overall complications were 3.5% (95% CI 1.6-5.8%), 4.1% (95% CI 1.6-7.5%), and 7.4% (95% CI 3.4-10.9%). The estimated pooled prevalence of hernia recurrence was 0.18% (95% CI 0.00-0.84%). CONCLUSIONS: Robotic technology has been progressively entering surgical thinking and gradually changing surgical procedures. Based on the results of the present study, the rTAPP seems feasible, safe, and effective in the short term for patients with unilateral and bilateral inguinal hernias. Further prospective studies and randomized controlled trials are needed to validate these findings.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair.

PURPOSE: The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. METHODS: PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. RESULTS: Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. CONCLUSIONS: This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Primary unilateral not complicated inguinal hernia with an effective, cheap, less invasive, and easy operation: the Trabucco repair.

BACKGROUND: In modern abdominal wall hernia surgery, the achievement of the most effective tailored repair for each specific defect with the less possible invasiveness, the quicker recovery, the lower costs and the fewer risk of local occurrences, recurrences and chronic pain is the most desirable and cutting-edge goal. METHODS: Since 1989 about 4219 primary unilateral not complicated inguinal hernias have been treated with specific indications with a sutureless and minimally invasive anterior open approach. The great majority of these procedures were performed under local anaesthesia in a day surgery regimen, with a systematic and careful nerve sparing, preservation of cremasteric muscle, and with a 3-5 cm skin incision. RESULTS: The minimally invasive sutureless nerve sparing open approach has shown a very low rate of seromas (0.45%), haematomas (0.24%) and infections (0.07%) while the width of skin incision challenges even laparoscopy. A significant reduction of both postoperative pain (2.7%) and chronic neuralgia (0.047%) has led to excellent outcomes in patients, also in terms of quality of life. Compared to the Lichtenstein's tension-free technique, which is at now the gold standard open treatment for primary inguinal hernia worldwide, there are no significant differences in the observed recurrence rate (well below 1%). CONCLUSION: In our experience of almost 30 years we have been able to experiment and refine more and more the sutureless technique proposed by Trabucco for the treatment of primitive inguinal hernia, peer to peer, improving the local anaesthesia and the ability to detect hidden defects during the repair (Spigelian included), reducing the width of the incisions and tractions on the tissues, introducing the concept of a gentle and bloodless "finger surgery" according to a minimally invasive, extremely anatomic, safe, inexpensive, very effective anterior open approach.

Impact of spleen-preserving total gastrectomy on postoperative infectious complications and 5-year overall survival: systematic review and meta-analysis of contemporary randomized clinical trials.

Background: The role of splenectomy in proximal gastric cancer is still debated. The objective of the present meta-analysis was to provide more-robust evidence about the effect of spleen-preserving total gastrectomy on postoperative infectious complications, overall morbidity, and 5-year overall survival (os). Methods: PubMed, embase, and the Web of Science were consulted. Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2 index and Cochran Q-test. Results: Three randomized controlled trials published between 2000 and 2018 were included. Overall, 451 patients (50.1%) underwent open total gastrectomy with spleen preservation and 448 (49.9%) underwent open total gastrectomy with splenectomy. The patients ranged in age from 24 to 78 years. No differences were found in the number of harvested lymph nodes (p = 0.317), the reoperation rate (p = 0.871), or hospital length of stay (p = 0.347). The estimated pooled risk ratios for infectious complications, overall morbidity, and mortality were 1.53 [95% confidence interval (ci): 1.09 to 2.14; p = 0.016], 1.51 (95% ci: 1.11 to 2.05; p = 0.008), and 1.23 (95% ci: 0.40 to 3.71; p = 0.719) respectively. The estimated pooled hazard ratio for 5-year os was 1.06 (95% ci: 0.78 to 1.45; p = 0.707). Conclusions: Spleen-preserving total gastrectomy should be considered in patients with curable gastric cancer because it is significantly associated with decreased postoperative infectious complications and overall morbidity, with no difference in the 5-year os. Those observations appear worthwhile for establishing better evidence-based treatment for gastric cancer.

Quality of life following ostomy reversal with purse-string vs linear skin closure: a systematic review.

BACKGROUND: The importance of the defunctioning stoma on minimizing anastomotic leak in colorectal surgery is well established. However, a defunctioning stoma can substantially impact on quality of life (QoL). Circumferential purse-string approximation (PSA) and linear skin closure (LSC) are the most commonly performed surgical technique for reversal of stoma. The aim of this review was to systemically review and meta-analyze available randomized controlled trials (RCTs) comparing PSA and LSC. METHODS: An electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) of RCTs comparing PSA and LSC was performed. Eight RCTs totalling 647 patients met the inclusion criteria and were included in this meta-analysis. RESULTS: Patient's satisfaction is significantly lower in PSA group during the first postoperative week, but it sharply improves afterwards and no difference were noted at 1 and 6 months between the two groups. Relative risk (RR) of developing a SSI is significantly lower in PSA compared to LSC group (RR 0.16 95% CI 0.09; 0.30; p = 0.0001), whereas incisional hernia (RR 0.53 95% CI 0.08; 3.53; p = 0.512), operative time (MD - 0.06 95% CI - 0.30; 0.17; p = 0.593), and hospital stay (MD - 0.09 (95% CI - 0.29-0.11; p = 0.401) remain similar. DISCUSSION: QoL was similar in both patients groups after the first postoperative week. PSA significantly reduced SSI rate. No difference was observed in incisional hernia rate, operative time, or length of hospital stay.

Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis.

Esophageal leaks remain a life-threatening postoperative complication of esophagectomy. Currently, self-expanding metal stents (SEMS) represent the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) has emerged and shown promising results in these patients. We conducted an electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) looking for studies comparing EVT and SEMS for the treatment of esophageal leak and/or perforation. Four studies including 163 patients matched the inclusion criteria. Esophageal leak closure rate is significantly higher with EVT than SEMS [pooled odds ratio 5.51 (95% CI 2.11-14.88; P < 0.001)]. Additionally, EVT has a shorter treatment duration [pooled mean difference -9.0 days (95% CI 16.6-1.4; P = 0.021)], lower major complication (P = 0.011), and in-hospital mortality (P = 0.002) rate compared to SEMS. EVT for esophageal leak is feasible and safe. It has the potential to become the new gold standard in the endoscopic treatment of esophageal leaks and perforations. However, further comparative studies with SEMS are needed to strengthen the current evidence.

Esophagectomy in patients with liver cirrhosis: a systematic review and Bayesian meta-analysis.

INTRODUCTION: Patients with esophageal carcinoma and concomitant liver cirrhosis carry a high operative risk and may be denied esophagectomy. We performed a systematic review of the literature and meta-analysis to investigate postoperative outcomes in these patients. METHODS: Studies reporting outcomes after esophagectomy in patients with liver cirrhosis were searched in Medline, Embase, Cochrane Library, ISI Web of Science, and Scopus until June 2017, matching the terms "liver cirrhosis", "esophageal neoplasm" and/or "esophageal surgery". Extracted data included study characteristics, demographic and clinical patient characteristics, type of surgical procedure, and postoperative outcomes. A systematic review and Bayesian meta-analysis were performed. RESULTS: Five observational, retrospective and single-arm studies with a total of 157 patients were included. The main cause of death was liver failure followed by pneumonia/sepsis and anastomotic leak. Ascites and pleural effusion were the most frequent postoperative complications (pooled rates 36% and 34%, respectively). The pooled morbidity rate was 74% (95% HPD=46-81%) while the pooled mortality was 18% (95% HPD=17-27%). Study heterogeneity (τ2) was low, ranging from 0.046 to 0.080. An incidental diagnosis of liver cirrhosis was reported in 15.6% of patients in one series. Five-year survival was similar between cirrhotic and non-cirrhotic patients but was statistically significantly higher in patients with MELD score<10. CONCLUSIONS: Sound scientific evidence with regard to efficacy and outcomes of esophagectomy in patients with concomitant liver cirrhosis is lacking. There is a need to properly select these frail patients to reduce postoperative morbidity and mortality rates.

Crura augmentation with Bio-A® mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients.

BACKGROUND: The potential utility of both non-absorbable and absorbable meshes to reinforce the esophageal hiatus and prevent recurrent hernia has been investigated in observational studies and a few randomized clinical trials. Use of absorbable mesh has been associated with lesser side-effects, but the long-term safety and effectiveness are still debated. This rather scanty clinical evidence is due to heterogeneity and bias regarding the type of mesh and operation used, the modalities of follow-up, and the reporting of objective results. OBJECTIVES: The aim of the study was to assess safety, quality of life, and recurrence-free probability after laparoscopic repair of hiatal hernia reinforced with a synthetic absorbable mesh. METHODS: Observational, retrospective, single-center cohort study. All patients with hiatal hernia who underwent laparoscopic crura repair using a biosynthetic mesh (Gore Bio A® tissue reinforcement, Flagstaff, AZ) were included. Pre- and post-operative symptoms were assessed with the GERD-HRQL questionnaire. Objective follow-up consisted of upper gastrointestinal endoscopy and barium swallow study. RESULTS: From September 2011 to March 2016, a total of 100 patients underwent hiatal hernia repair using a Bio-A® mesh. All surgical procedures were completed laparoscopically. Postoperative morbidity rate was 10%. All patients had a minimum follow-up of 6 months, and the median follow-up was 30 (IQR = 22) months. No mesh-related complications occurred. The incidence of recurrent hernia ≥2 cm was 9%, and eight of the nine patients had a preoperative type III hernia. The median GERD-HRQL score was significantly reduced after operation (p < 0.001). The recurrence-free probability at 1 and 5 years was, respectively, 0.99 (CI 0.97-1.00) and 0.84 (CI 0.74-0.97), and no reoperation was required. No association was found between age, BMI, hernia size, previously failed surgical repairs and hernia recurrence. CONCLUSIONS: The use of a synthetic absorbable mesh to reinforce the esophageal hiatus is safe and appears to be effective and durable over a medium-term follow-up.