Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis.

BACKGROUND: Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC. METHODS: We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE. RESULTS: A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias. DISCUSSION: For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR. REVIEW REGISTRATION: PROSPERO CRD42021270445.

The role of routine groin ultrasonography in the management of inguinal hernia.

BACKGROUND: Groin ultrasonography (US) has been used as an adjunct to inguinal hernia diagnosis, but there is limited evidence as to whether its use affects surgical decision-making. The primary aim of this study was to examine whether groin US affects surgical management of inguinal hernia; the secondary goal was to estimate the frequency of groin US ordered before surgical consultation. METHODS: We performed a retrospective chart review of 400 consecutive patients aged older than 18 years referred to 1 of 4 general surgeons in Calgary, Alberta, for inguinal hernia between January 2014 and January 2015. Bilateral groin examinations were entered as separate entries into the database. Outcomes assessed included the frequency of groin US examinations performed within 1 year before the general surgery consultation, presence of inguinal hernia on clinical examination (CE), presence of inguinal hernia on groin US, and whether the hernia proceeded to herniorrhaphy. RESULTS: A total of 476 groins in the 400 patients (354 [88.5%] male; mean age 53.5 yr [standard deviation 15.2 yr]) were evaluated for a hernia during the study period. Groin US was performed before general surgery consultation in 336 cases (70.6%). Overall, 364 (76.5%) of the hernias were clinically palpable; of the 364, 220 (60.4%) had preconsultation US, even in the presence of a positive CE finding. Of the 112 groins that did not have a clinically palpable hernia, 103 (92.0%) underwent preconsultation US. Of the 476 groins, 315 (66.2%) underwent inguinal hernia repair: 310 (85.2%) of the 364 with clinically palpable hernias and 5 (4.8%) of the 103 with clinically negative findings but positive groin US findings. Surgical decision-making based on CE findings occurred in 390 cases (81.9%) overall, whereas surgery based on groin US findings alone occurred in 5 of 336 cases (1.5%). CONCLUSION: Routine groin US was frequently performed before general surgery consultation, whether a hernia was detectable on clinical examination or not. Positive groin US results alone infrequently affected whether the patient proceeded to surgery. Clinical examination findings played a larger role in surgical decision-making than groin US results. Eliminating the practice of routine groin US may provide considerable health care cost savings.

Parasternal intercostal function during sustained hypoxia.

Ventilatory response to sustained isocapnic hypoxia in adult humans and other mammals is characterized by a biphasic pattern, with attenuation of neuromotor output to the diaphragm. However, there is no a priori reason that hypoxia-mediated attenuation of respiratory drive would be a common event among other respiratory muscles. At present, little is known about the function of the chest wall muscles during sustained hypoxia. As an obligatory inspiratory muscle with potential to act as a surrogate for neural drive to the relatively inaccessible costal diaphragm, parasternal intercostal has gained interest clinically: its function during a sustained hypoxic insult, as may occur in respiratory failure, warrants investigation. Therefore, in 11 chronically instrumented awake canines, we simultaneously recorded muscle length and shortening and electromyogram (EMG) activity of the parasternal chest wall inspiratory muscle, along with breathing pattern, during moderate levels of sustained isocapnic hypoxia lasting 20-25 min (mean 80 ± 2% oximeter oxygen saturation). Phasic inspiratory shortening and EMG activity of the parasternal intercostal were observed throughout room air and hypoxic ventilation in all animals. Temporal changes in parasternal intercostal shortening tracked the biphasic changes in ventilation during sustained hypoxia. Mean shortening and EMG activity of parasternal intercostal muscle increased significantly with initial hypoxia (P < 0.01) and then markedly declined with constant hypoxia (P < 0.05). We conclude that attenuation of central neural respiratory drive extends to the primary chest wall inspiratory muscle, the parasternal intercostal, during sustained hypoxia, thus directly contributing to biphasic changes in ventilation.NEW & NOTEWORTHY With the potential to act as a surrogate for the generally inaccessible costal diaphragm, parasternal intercostal has gained great interest clinically as a muscle to monitor neural drive and function in respiratory disease. This study demonstrates for the first time the impact of sustained hypoxia on neural activation and mechanical contraction of the parasternal intercostals. Parasternal intercostals reveal a biphasic action during the time-dependent hypoxic response, with a transient increase in shortening and EMG activity with acute hypoxia followed by a progressive decline when hypoxia is sustained.

Challenging delayed bleeding after an Ivor Lewis oesophagectomy.

A 66-year-old man underwent a minimally invasive oesophagectomy for oesophageal adenocarcinoma. Surgery and recovery were routine; however, he represented 8 days later with a massive upper gastrointestinal bleed. He was stabilized, but over a 2-week period experienced several bleeds requiring transfusion and multiple endoscopies, all showing a prominent luminal vessel at the oesophago-gastric (OG) anastomosis. Haemostatic clipping was attempted resulting in pulsatile bleeding and transfer to the radiology suite where angiography showed extravasation of contrast at the OG anastomosis from the terminal portion of the gastro-epiploic arcade. Coil embolization was successful and did not result in ischaemia. It was our standard to construct the OG anastomosis with the end-to-end anastomosis circular stapler (DST™ Series EEA™), 4.8-mm staple height. However, we now use the 3.5-mm staple height for improved haemostasis and ensure that the area for anastomosis is cleared of omental tissue so as not to incorporate a visible vessel.

Early Routine Use of Upper GI Contrast Series Post Paraesophageal Hernia Repair: A Single Institution Consecutive Case Series.

INTRODUCTION: There is conflicting evidence with regard to the routine use of upper gastrointestinal contrast series in detecting early complications post paraesophageal hernia repair (PEHR). METHODS: All cases booked for a PEHR between January 2007 and September 2015 were identified using hospital records. Standard demographic, operation, and imaging data were extracted. RESULTS: We retrospectively identified 391 PEHR cases between January 2007 and September 2015. The mean age at the index operation was 66.7 years with a female predominance. The majority of index operations were elective and completed for a large paraesophageal hernia. Contrast studies were reported as normal in 70.6%, a leak in 0.3%, an obstruction in 27.9%, and early recurrence in 1.0%. Reoperation was required in 1.8% of cases. CONCLUSION: Routine upper gastrointestinal contrast studies post-PEHR changed management in 0.8% of cases and were unhelpful in determining the need for early reoperation in 57.1% of cases requiring reoperation.

Sleeve gastrectomy and hypertension: a systematic review of long-term outcomes.

INTRODUCTION: Bariatric surgery has been shown to be a safe and durable intervention for patients struggling with obesity and metabolic syndrome, including hypertension. Buchwald et al. reported hypertension resolution rates in 67.1% and improvement in 78.5% following aggregate bariatric surgery. The laparoscopic sleeve gastrectomy (LSG) is becoming increasingly utilized as a primary bariatric surgery, but lacks long-term outcome data. There are a growing number of studies reporting outcome data beyond 5 years. OBJECTIVE: This study aims to systematically evaluate the efficacy of laparoscopic sleeve gastrectomy on hypertension amongst obese patients. MATERIALS AND METHODS: A comprehensive literature search was conducted through Medline, Embase, Scopus, Web of Science, Dare, Cochrane library, and HTA database. The search terms used were broad: sleeve gastrectomy AND hypertension OR blood pressure. Adult patients undergoing LSG with follow-up hypertension outcome results of at least 5 years were included. Revisional surgeries were excluded. Two independent reviewers were used. RESULTS: Fourteen studies were included in this systematic review, which included 3550 subjects in total. Mean age was 41.1 ± 10.7 years. Mean pre-operative BMI and weight were 47.7 ± 8.83 kg/m2 and 272.8 ± 48.4 lb, respectively. Pre-operative prevalence of hypertension was 36.5% (range 6.7-91%) which dropped to 14.79% (range 0-33.3%) at approximately 5-year follow-up. Hypertension resolved in 62.17% (range 0-100%) of patients and improved in 35.7% (range 13.3-76.9%) at a mean of 5.35 years of follow-up. CONCLUSION: From this systematic review, LSG is an effective intervention for bariatric patients with hypertension. In addition to the observed reduction in the incidence of hypertension, it is likely that LSG may lead to additional health system benefits such as cost savings due to reductions in antihypertensive medications. Further prospective studies should include estimates of cost savings associated with reductions in chronic antihypertensive medication usage.

A Shorter Circular Stapler Height at the Gastrojejunostomy during a Roux-En-Y Gastric Bypass Results in Less Strictures and Bleeding Complications.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is prone to a number of complications, most notably at the gastrojejunostomy (GJ) staple line. The circular stapler technique is a common method used to create the GJ anastomosis. Although recent studies have shown a decreased rate of anastomotic strictures with shorter stapler heights, the optimal circular stapler height to use remains controversial. We therefore completed a retrospective cohort study within the Alberta Provincial Bariatric Program (APBP) to compare outcomes between the 3.5 mm and 4.8 mm stapler heights. We identified 215 patients who had a LRYGB done between the years 2015 and 2017. 143 patients had the GJ constructed with a 3.5 mm circular stapler height, with the remaining 72 patients having the GJ fashioned with a 4.8 mm stapler height. The rate of anastomotic stricturing was lower in the 3.5 mm stapler group compared to the other cohort (3.5 versus 13.9%, resp., p=0.008). Likewise, the overall rate of bleeding complications was lower in the 3.5 mm stapler group compared to the 4.8 mm group (6.3 versus 15.3%, resp., p=0.04). The rate of anastomotic stricturing and postoperative bleeding is lower with the use of a 3.5 mm circular stapler compared to a 4.8 mm circular stapler when forming the GJ.

Diagnostic accuracy of transabdominal ultrasonography for gallbladder polyps: systematic review.

BACKGROUND: Previous research has shown variable but generally poor accuracy of transabdominal ultrasonography in the diagnosis of gallbladder polyps. We performed a systematic review of the literature with the aim of helping surgeons interpret and apply these findings in the preoperative assessment and counselling of their patients. METHODS: We searched PubMed, MEDLINE and the Cochrane database using the keywords "gallbladder," "polyp," "ultrasound," "pathology" and "diagnosis" for English-language articles published after 1990 with the full-text article available through our institutional subscriptions. Polyps were defined as immobile features that on transabdominal ultrasonography appear to arise from the mucosa and that lack an acoustic shadow, and pseudopolyps were defined as features such as inflammation, hyperplasia, cholesterolosis and adenomyomatosis that convey no risk of malignant transformation. RESULTS: The search returned 1816 articles, which were narrowed down to 14 primary sources involving 15 497 (range 23-13 703) patients who had preoperative transabdominal ultrasonography, underwent cholecystectomy and had postoperative pathology results available. Among the 1259 patients in whom a gallbladder polyp was diagnosed on ultrasonography, 188 polyps were confirmed as true polyps on pathologic examination, and 81 of these were found to be malignant. Of the 14 238 patients for whom a polyp was not seen on ultrasonography, 38 had a true polyp on pathologic examination, none of which were malignant. For true gallbladder polyps, transabdominal ultrasonography had a sensitivity of 83.1%, specificity of 96.3%, positive predictive value of 14.9% (7.0% for malignant polyps) and negative predictive value of 99.7%. CONCLUSION: Transabdominal ultrasonography has a high false-positive rate (85.1%) for the diagnosis of gallbladder polyps. Further study of alternative imaging modalities and reevaluation of existing management guidelines are warranted.

CONTEXTE: Des recherches antérieures ont montré la précision variable, mais généralement médiocre, de l'échographie transabdominale pour le diagnostic des polypes de la vésicule biliaire. Nous avons procédé à une revue systématique de la littérature scientifique afin d'aider les chirurgiens à interpréter et à appliquer ces résultats lors de l'évaluation préopératoire, et à conseiller leurs patients. MÉTHODES: Nous avons interrogé les réseaux PubMed, MEDLINE et la base de données Cochrane à partir des mots clés « gallbladder ¼, « polyp ¼, « ultrasound ¼, « pathology ¼ et « diagnosis ¼ (vésicule biliaire, polype, échographie, pathologie et diagnostic) pour recenser les articles en langue anglaise publiés après 1990, pour lesquels le texte intégral était accessible par abonnement institutionnel. À l'échographie, les polypes étaient définis comme des structures fixes semblant émaner de la muqueuse et dépourvues d'ombre acoustique, et les pseudopolypes étaient définis par des caractéristiques telles que l'inflammation, l'hyperplasie, la cholestérolose et l'adénomyomatose ne comportant pas de risque de transformation maligne. RÉSULTATS: La recherche a généré 1816 articles qui ont été ramenés à 14 sources principales regroupant 15 497 (éventail, 23-13 703) patients ayant subi une échographie transabdominale préopératoire et une cholécystectomie, et pour lesquels on disposait des résultats de l'examen anatomopathologique postopératoire. Sur les 1259 patients chez qui des polypes intravésiculaires ont été diagnostiqués à l'échographie, 188 polypes ont été jugés vrais à l'examen anatomopathologique, et 81 d'entre eux se sont révélés malins. Parmi les 14 238 patients chez lesquels aucun polype n'avait été détecté à l'échographie, 38 étaient porteurs d'un vrai polype à l'examen anatomopathologique et aucun ne s'est révélé malin. En ce qui concerne les vrais polypes intravésiculaires, l'échographie transabdominale a une sensibilité de 83,1 %, une spécificité de 96,3 %, une valeur prédictive positive de 14,9 % (7,0 % dans le cas des polypes malins) et une valeur prédictive négative de 99,7 %. CONCLUSION: L'échographie transabdominale présente un taux de résultats faux positifs élevé (85,1 %) pour le diagnostic des polypes de la vésicule biliaire. Il faudra approfondir la recherche sur d'autres techniques d'imagerie et réévaluer les lignes directrices actuelles de prise en charge.

Sleeve Gastrectomy and Type 2 Diabetes Mellitus: a Systematic Review of Long-Term Outcomes.

Long-term T2DM resolution rates are not well established following the laparoscopic sleeve gastrectomy (LSG). The aim of this paper was to systematically review the evidence on the efficacy of the LSG on long-term T2DM resolution. A comprehensive electronic literature search was conducted. Included studies reported 5-year follow-up of T2DM outcomes following the LSG. Eleven studies (n = 1354) were included in the systematic review. T2DM patients (n = 402) encompassed 29.7 % of patients. Diabetes prevalence decreased post-operatively to 20.5 % at 5 years, with diabetes resolution occurring in 60.8 % of patients. Mean plasma glucose levels and haemoglobin A1c values fell from 170.3 to 112.0 mg/dL and 8.3 to 6.7 % respectively at the 5-year mark. The LSG is an effective long-term metabolic surgery for patients with T2DM.

The effect of simulation in improving students' performance in laparoscopic surgery: a meta-analysis.

BACKGROUND: There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95 % confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. RESULTS: Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.98, 95 % CI: 1.20-2.77; P < 0.01), were more careful in handling various body tissue (d = 1.08, 95 % CI: 0.36-1.80; P < 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95 % CI: 0.30-2.47; P < 0.05). CONCLUSION: Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly.

BACKGROUND: Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE. METHODS: A retrospective review of patients with massive splenomegaly undergoing LAS or HALS after preoperative SAE during the years 2004 to 2006 at the authors' institution was performed. Patients with a craniocaudal spleen length of 20 cm or greater were included in the study irrespective of their primary diagnosis. The data collected included information on patient demographics, operative details, rates of conversion to open procedures, perioperative blood transfusions, and postoperative complications. Routine Doppler ultrasound of the abdomen was performed on postoperative days 7 and 30 to screen for portal vein thrombosis (PVT). RESULTS: A total of 19 patients were identified. The median spleen length was 23 cm, and the median spleen weight was 1,740 g. Nine patients underwent LAS, and 10 underwent HALS. The median operative time was 130 min, and the median hospital stay was 6 days. There were no conversions to open laparotomy. The median estimated blood loss was 200 ml. One patient required reoperation 24 h after LAS due to bleeding, and PVT developed in three patients postoperatively. CONCLUSIONS: In the setting of massive splenomegaly, LAS or HALS with preoperative SAE is safe and has a low conversion rate. Postoperative imaging surveillance for PVT should be performed routinely in this patient population.

Management of acute paraesophageal hernia.

BACKGROUND: Acute paraesophageal hernia is a surgical emergency presenting with sudden chest or abdominal pain, dysphagia, vomiting, retching or significant anemia. Severe cases can present with respiratory failure or systemic sepsis. This can be due to gastric volvulus, incarceration, strangulation, severe bleeding or perforation. Traditionally this has been treated with an open surgery. The purpose of this study is to develop a management algorithm and evaluate the role of a laparoscopic approach for these cases. METHODS: A retrospective chart review was performed for patients operated on for paraesophageal hernia at the Peter Lougheed Centre from 2004 to 2007 inclusive. Patients admitted with acute symptoms requiring emergency surgery were selected for the study. RESULTS: Twenty patients were identified. Seventeen patients underwent successful laparoscopic repair including reduction of the hernia content, excision of the sac, crural closure, and fundoplication (Dor or Nissen). Fifteen of these were done semi-urgently. Three patients had open repair. One patient was converted to open due to ischemic gastric perforation and peritoneal contamination. Another patient had right thoracotomy followed by laparotomy for mediastinal contamination. A third patient with a body mass index (BMI) of 49 kg/m(2) was converted to open for a type VI paraesophageal hernia. Mean operating time for the laparoscopic group was 190.5 min, blood loss was minimal, and mean postoperative hospital stay was 8.2 days. There were no significant perioperative complications. All patients were tolerating regular diet on short-term follow-up. CONCLUSION: Laparoscopic repair of acute paraesophageal hernia is safe and feasible with low morbidity and mortality. It affords all the benefits of minimally invasive surgery in a group of patients that are often elderly and suffer from multiple medical problems. Based on our experience, we advocate the laparoscopic technique to repair acute paraesophageal hernias in patients with no obvious perforation. A management algorithm is also suggested.

Hepatic vein injury during laparoscopic cholecystectomy: the unappreciated proximity of the middle hepatic vein to the gallbladder bed.

Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter = 2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage.

Well differentiated intrahepatic cholangiocarcinoma in the setting of biliary papillomatosis: a case report and review of the literature.

A 64-year-old man presented with long-standing, vague, epigastric abdominal pain. History, physical examination and laboratory studies were noncontributory. However, serial computed tomography scans revealed a rapidly progressive mass in segment 2 of the liver. Surprisingly, surgical pathology revealed a well-differentiated intrahepatic cholangiocarcinoma associated with biliary papillomatosis (BP). BP is a rare, benign and potentially fatal disease of the intra- and extrahepatic bile ducts. It is typified by numerous multicentric papillary fronds arising from biliary columnar epithelium. Most patients present with symptoms of jaundice and cholangitis. Although a benign disease, a review of the literature demonstrated that BP often recurs after surgical resection, carries a poor prognosis and has a moderately high malignant transformation rate. Treatment options for BP include surgical resection, transplant, ablation, stenting and/or bypass.