Laparoscopic appendectomy with single port vs conventional access: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach. METHODS: Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel-Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool. RESULTS: Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study. CONCLUSIONS: This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar.

Papillary Thyroid Cancer Prognosis: An Evolving Field.

Over the last few years, a great advance has been made in the comprehension of the molecular pathogenesis underlying thyroid cancer progression, particularly for the papillary thyroid cancer (PTC), which represents the most common thyroid malignancy. Putative cancer driver mutations have been identified in more than 98% of PTC, and a new PTC classification into molecular subtypes has been proposed in order to resolve clinical uncertainties still present in the clinical management of patients. Additionally, the prognostic stratification systems have been profoundly modified over the last decade, with a view to refine patients' staging and being able to choose a clinical approach tailored on single patient's needs. Here, we will briefly discuss the recent changes in the clinical management of thyroid nodules, and review the current staging systems of thyroid cancer patients by analyzing promising clinicopathological features (i.e., gender, thyroid auto-immunity, multifocality, PTC histological variants, and vascular invasion) as well as new molecular markers (i.e., BRAF/TERT promoter mutations, miRNAs, and components of the plasminogen activating system) potentially capable of ameliorating the prognosis of PTC patients.

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair.

BACKGROUND: Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months. MATERIAL: A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation. RESULTS: Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542). CONCLUSION: The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

Intersigmoid Hernia: A Forgotten Diagnosis-A Systematic Review of the Literature over Anatomical, Diagnostic, Surgical, and Medicolegal Aspects.

INTRODUCTION: Intersigmoid hernia is a hernia of the small bowel into the intersigmoid fossa. It is well known to be a rare condition. Recent reports reveal that the preoperative differentiation of intersigmoid hernias is difficult and the diagnosis is often confirmed during the laparotomic exploration. Due to the vague clinical manifestation in most cases, the surgical treatment is frequently delayed. MATERIALS AND METHODS: In this study, we systematically reviewed the literature up to 2019 covering 114 studies and 124 patients with an intersigmoid hernia. The purpose of this work is to improve the understanding of the anatomical aspects, clinical presentation, diagnosis, and treatment of intersigmoid hernia so as to assist the preoperative differentiation of these hernias when presented as acute abdomen in the emergency department. RESULTS: The diameter of the intersigmoid recess was reported with mean 2.65 cm (range 1-10 cm, SD 1.15 cm) and the length of the incarcerated small intestine was between 3 cm (min) and 150 cm (max): mean 25.25 cm, SD 35.04 cm. The diameter of the sigmoid recess was greater in patients who underwent resection due to strangulation (mean 3.31 cm, SD 1.53 cm) compared to those who underwent only reduction of the hernia (mean 2.35 cm, SD 0.74 cm). The time from onset to operation was less in patients undergoing resection surgery due to throttling (mean 3.03 days, SD 3.01 days) compared to those who underwent only a reduction of hernia incarceration (mean 8.49 days, SD 6.83 days). CONCLUSION: Intersigmoid hernia is often a forgotten diagnosis and a clinical challange due to its anatomical characteristics.

Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies.

BACKGROUND: Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy. METHODS: We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression. RESULTS: On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced. CONCLUSIONS: Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Evaluation of Surgical Site Infection in Mini-invasive Urological Surgery.

Surgical Site Infection (SSI) is the most frequent source of infection in surgical patients and the second most frequent cause of hospital-acquired infection. The primary aim of this prospective study was to compare SSI occurrences between minimally invasive surgery (MIS) and open urological surgery. Secondly, perioperative outcomes were evaluated in two different approaches. A consecutive group of 60 patients undergoing urological surgery were prospectively enrolled in a single high-volume center between May and October 2018. We included procedures that were performed by minimally invasive or traditional techniques. We evaluated and compared the incidence of SSI and perioperative outcomes in terms of intraoperative bleeding, post-operative complications, postoperative pain, patient satisfaction with the analgesic treatment, time to flatus, time of oral intake and mobilization, and length of hospital stay. The two groups were homogeneous with regard to demographic data. Superficial incisional SSIs were diagnosed in 10% of cases (3/30) in the second group and 0% in the first (p<0.05); space/organ SSIs developed in 4 patients, which were diagnosed by ultrasound scan and confirmed by abdominal CT: 1 patient (3.3%) in group 1 showed an infected lymphocele, whereas 1 case of infected lymphocele and 2 cases of pelvic abscess were detected in group 2 (10%, p<0.05). All the perioperative outcomes as well as were overall complication rate favored MIS (p<0.05). The use of minimally invasive techniques in urological surgery reduced the risk of SSI by comparison with a traditional approach. In addition, MIS was associated with better perioperative outcomes and a lower overall complication rate.

The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience.

This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.

Cholecystectomy for acute cholecystitis in octogenarians: impact of advanced age on postoperative outcome.

BACKGROUND: The number of surgical operations in elderly patients is increasing due to the aging demographics of western populations. The aim of the present study was to investigate the peri-operative outcome of octogenarian patients undergoing cholecystectomy for acute cholecystitis. METHODS: We performed a retrospective analysis including all patients who underwent cholecystectomy for acute cholecystitis from January 2013 to December 2017. Records were collected prospectively from two centers: 1) Unit of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum University, Bologna; 2) "Advanced Surgical Technologies" Department of Surgical Sciences, Umberto I University Hospital, La Sapienza University, Rome. Patients were divided by age (≥ or <80 years) and peri-operative outcomes were compared. RESULTS: During the study period, 464 patients were operated for acute cholecystitis in the two centers. Sixty-three (14%) patients were octogenarians (group 1) and median age was 84.8±3.9 years. Four hundred and one patients (86%) were younger than 80 years (group 2) with median age of 55.3±15.3 years. Forty-four per cent of group-1 patients underwent laparoscopic cholecystectomy versus 81% of the younger group (P<0.01). Elderly patients had a higher percentage of overall complications (25% vs. 9%; P=0.03) and a longer median postoperative length of stay (7.2±6.8 vs. 4.6±7.7; P=0.04). Overall mortality was 1%: two patients died in group-1 and one in group-2 (P=0.50). However, on multivariate analysis age older than 80 years was not found to be an independent risk factor for postoperative morbidity and mortality. CONCLUSIONS: The results of this study suggest that cholecystectomy for acute cholecystitis in octogenarians is a relatively safe procedure with an acceptable risk of complications and a postoperative hospital stay comparable to younger ones.

Urgency surgical treatment for duodenal GISTs: analysis of aged patients and review of the literature.

INTRODUCTION: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms (85%) of the gastrointestinal (GI) tract; duodenal GISTs constitute 3-5% of all GISTs and represent 10-30% of all malignant tumours of the duodenum. Rarely, patients present severe bowel obstruction, perforation or severe bleeding. The radical resection with complete removal of the tumour remains the main therapeutic approach. We performed a local resection in patients with suspected GIST admitted for emergency treatment for GI bleeding. CASES: We present three cases of patients admitted for GI bleeding. The cause could be a GIST bleeding. In all cases, local resection was performed without a pancreaticoduodenectomy. Histological examination on surgical preparations showed that in two cases it was a GIST and in one case, it was a leiomyoma. DISCUSSION: Surgery remains the treatment of choice in the case of a GIST primitive without evidence of metastases, even for patients who are hospitalized for a bleeding emergency. Wide resections are not needed; it is important to remove completely the disease. In the case of duodenal GIST, it is important to get negative margins near the head of the pancreas, and this could take a PD. According to our experience and to the literature review, we believe that if the duodenal papilla or the periampullary region is not interested, you must perform a local resection. This is also because non-malignant tumours may present as GISTs and in these cases it is not recommended to run a PD. CONCLUSION: The treatment of choice for duodenal GISTs is complete surgical resection with negative resection margins. When the papilla or the periampullary region is involved we choose to perform pancreaticoduodenectomy; otherwise it is better to perform a local resection. In fact, local resection has lower morbidity and mortality, with a comparable outcome.

Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery.

INTRODUCTION: Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications. MATERIALS AND METHODS: We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation. DISCUSSION: Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer. CONCLUSIONS: The surgical choice should be made case by case (custom-made), not based on age only.

Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient.

BACKGROUND: Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS: The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS: A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS: Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION: Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS: Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.

Is it safe and useful, laparoscopic peritoneal lavage in the treatment of acute diverticulitis of octogenarian patients? A multicenter retroprospective observational study.

BACKGROUND: Diverticular disease of the colon also affects older people. Generally, older patients with diverticulitis may be regarded as too risky to undergo surgery. This retroprospective multicentric observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage (LPL) in elderly patients with perforated sigmoid diverticulitis. PATIENTS AND METHOD: We hospitalized in urgency 100 patients, aged over 75, for sigmoid diverticulitis. Sixty-nine patients were treated with conservative medical therapy, while 31 were treated surgically, in which the surgery was performed in urgency in 18 cases, while in election in 13 cases. Laparoscopic peritoneal lavage was made in urgency in five cases. RESULTS: The mean age of the sample was 81.72. Thirty-one patients underwent surgery, and five patients were treated in urgency with laparoscopic peritoneal lavage. Perioperative mortality was zero. None of the patients who underwent laparoscopic peritoneal lavage showed recurrent disease. CONCLUSION: Diagnostic laparoscopy can be useful in elderly patient, since these patients may benefit from a more conservative surgical strategy. The selection of patients to be subjected to laparoscopic lavage must be very rigorous.

Laparoscopic peritoneal lavage: our experience and review of the literature.

INTRODUCTION: Over the years various therapeutic techniques for diverticulitis have been developed. Laparoscopic peritoneal lavage (LPL) appears to be a safe and useful treatment, and it could be an effective alternative to colonic resection in emergency surgery. AIM: This prospective observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage in perforated sigmoid diverticulitis. MATERIAL AND METHODS: We surgically treated 70 patients urgently for complicated sigmoid diverticulitis. Thirty-two (45.7%) patients underwent resection of the sigmoid colon and creation of a colostomy (Hartmann technique); 21 (30%) patients underwent peritoneal laparoscopic lavage; 4 (5.7%) patients underwent colostomy by the Mikulicz technique; and the remaining 13 (18.6%) patients underwent resection of the sigmoid colon and creation of a colorectal anastomosis with a protective ileostomy. RESULTS: The 66 patients examined were divided into 3 groups: 32 patients were treated with urgent surgery according to the Hartmann procedure; 13 patients were treated with resection and colorectal anastomosis; 21 patients were treated urgently with laparoscopic peritoneal lavage. We had no intraoperative complications. The overall mortality was 4.3% (3 patients). In the LPL group the morbidity rate was 33.3%. CONCLUSIONS: Currently it cannot be said that LPL is better in terms of mortality and morbidity than colonic resection. These data may, however, be proven wrong by greater attention in the selection of patients to undergo laparoscopic peritoneal lavage.

Analysis of long-term results after liver surgery for metastases from colorectal and non-colorectal tumors: A retrospective cohort study.

BACKGROUND: During the last decade, criteria for liver resection were extended thanks to surgical and oncological developments, thus increasing the number of surgeries for non-colorectal liver metastases. However, the real advantages of surgery in this category of patients remain debated, due to the few studies available in the literature. The present study aims to analyze liver surgery performed for metastatic disease at a single referral center, comparing outcomes of patients that underwent resections for colorectal and non-colorectal metastases. METHODS: The overall study period was January 2005-May 2015. A total of 170 patients were selected from the institutional database and then included in the analysis. Patients and tumors characteristics were reported. Overall survival and subgroup analyses based on different primary malignancies were performed. The Kaplan-Meier method was used. RESULTS: The mean age of the patients was 67.68 ± 10.98 years. Primary malignancies distribution resulted as follows: colorectal (77.1%), genitourinary (7.6%), neuroendocrine (5.3%), breast (4.7%), foregut (2.9%), melanoma (2.4%). The overall survival rates at 1, 3, 5 years, were 96.2%, 42.8% and 14.7%, respectively. The survival analysis showed a mean overall survival of 54 months in the colorectal metastases group vs 32 months in the non-colorectal liver metastases group (HR = 5.92, P = 0.015). CONCLUSION: Surgery for patients with non-colorectal liver metastases must be considered in the context of a multidisciplinary treatment where chemotherapy plays the main role. International guidelines and a specific consensus on this field are desirable to offer the best available therapy for the metastatic liver disease. ETHICS AND DISSEMINATION: This study is conducted in compliance with ethical principles originating from the Helsinki Declaration, within the guidelines of Good Clinical Practice and relevant laws/regulations. TRIAL REGISTRATION NUMBER: researchregistry898.

Robotic Total Gastrectomy With Intracorporeal Robot-Sewn Anastomosis: A Novel Approach Adopting the Double-Loop Reconstruction Method.

Gastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis.Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run.A new reconstructive approach, not yet described in literature, was recently adopted at our Center.Robotic total gastrectomy with D2 lymphadenectomy and a so-called "double-loop" reconstruction method with intracorporeal robot-sewn anastomosis (Parisi's technique) was performed in all reported cases.Preoperative, intraoperative, and postoperative data were collected and a technical note was documented.All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred.Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery.The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcomes.

Total or near-total thyroidectomy versus subtotal thyroidectomy for multinodular non-toxic goitre in adults.

BACKGROUND: Total thyroidectomy (TT) and subtotal thyroidectomy (ST) are worldwide treatment options for multinodular non-toxic goitre in adults. Near TT, defined as a postoperative thyroid remnant less than 1 mL, is supposed to be a similarly effective but safer option than TT. ST has been shown to be marginally safer than TT, but it may leave an undetected thyroid cancer in place. OBJECTIVES: The objective was to assess the effects of total or near-total thyroidectomy compared to subtotal thyroidectomy for multinodular non-toxic goitre. SEARCH METHODS: We searched the Cochrane Library, MEDLINE, PubMed, EMBASE, as well as the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 18 June 2015 for all databases. No language restrictions were applied. SELECTION CRITERIA: Two review authors independently scanned the abstract, title or both sections of every record retrieved to identify randomised controlled trials (RCTs) on thyroidectomy for multinodular non-toxic goitre for further assessment. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We calculated the odds ratio (OR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. A random-effects model was used for pooling data. MAIN RESULTS: We examined 1430 records, scrutinized 14 full-text publications and included four RCTs. Altogether 1305 participants entered the four trials, 543 participants were randomised to TT and 762 participants to ST. A total of 98% and 97% of participants finished the trials in the TT and ST groups, respectively. Two trials had a duration of follow-up between 12 and 39 months and two trials a follow-up of 5 and 10 years, respectively. Risk of bias across studies was mainly unknown for selection, performance and detection bias. Attrition bias was generally low and reporting bias high for some outcomes. In the short-term postoperative period no deaths were reported for both TT and ST groups. However, longer-term data on all-cause mortality were not reported (1284 participants; 4 trials; moderate quality evidence). Goiter recurrence was lower in the TT group compared to ST. Goiters recurred in 0.2% (1/425) of the TT group compared to 8.4% (53/632) of the ST group (OR 0.05 (95% CI 0.01 to 0.21); P < 0.0001; 1057 participants; 3 trials; moderate quality evidence). Re-intervention due to goitre recurrence was lower in the TT group compared to ST. Re-intervention was necessary in 0.5% (1/191) of TT patients compared to 0.8% (3/379)of ST patients (OR 0.66 (95% CI 0.07 to 6.38); P = 0.72; 570 participants; 1 trial; low quality evidence). The incidence of permanent recurrent laryngeal nerve palsy was lower for ST compared with TT. Permanent recurrent laryngeal nerve palsy occurred in 0.8% (6/741) of ST patients compared to 0.7% (4/543) of TT patients (OR 1.28, (95% CI 0.38 to 4.36); P = 0.69; 1275 participants; 4 trials; low quality evidence). The incidence of permanent hypoparathyroidism was lower for ST compared with TT. Permanent hypoparathyroidism occurred in 0.1% (1/741) of ST patients compared to 0.6% (3/543) of TT patients (OR 3.09 (95% CI 0.45 to 21.36); P = 0.25; 1275 participants: 4 trials; low quality evidence). The incidence of thyroid cancer was lower for ST compared with TT. Thyroid cancer occurred in 6.1% (41/669) of ST patients compared to 7.3% (34/465)of TT patients (OR 1.32 (95% CI 0.81 to 2.15); P = 0.27; 1134 participants; 3 trials; low quality evidence). No data on health-related quality of life or socioeconomic effects were reported in the included studies. AUTHORS' CONCLUSIONS: The body of evidence on TT compared with ST is limited. Goiter recurrence is reduced following TT. The effects on other key outcomes such as re-interventions due to goitre recurrence, adverse events and thyroid cancer incidence are uncertain. New long-term RCTs with additional data such as surgeons level of experience, treatment volume of surgical centres and details on techniques used are needed.

Robotic versus Laparoscopic Approach in Colonic Resections for Cancer and Benign Diseases: Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes. MATERIALS AND METHODS: A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics. RESULTS: A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches. CONCLUSIONS: The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections.