Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients.

BACKGROUND: Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another. METHODS: To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis. RESULTS: Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928). CONCLUSION: Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Severe community acquired adenovirus pneumonia in an immunocompetent host successfully treated with IV Cidofovir.

Adenovirus is a common cause of acute febrile respiratory infection in children and are generally self-limiting although pneumonia can occur in neonates and adults with compromised immunity. However, severe adenovirus pneumonia in healthy adults has been rarely described. Here, we report a case of severe community-acquired adenovirus pneumonia in a previously healthy patient successfully treated with intravenous Cidofovir.

A mimic of bronchogenic carcinoma - pulmonary melioidosis.

We report a case of a patient with pulmonary melioidosis which radiologically mirrored a bronchogenic carcinoma with mediastinal lymphadenopathy. Such findings were observed in a Computed Tomography (CT) scan (Thorax) and Positron Emission Tomography (PET) scan (Body) in a previously healthy 57-year-old man with no significant medical risk factors for melioidosis other than his previous exposures to soil during outfield military training in Thailand, 37 and 28 years ago. He presented with acute symptoms of dry cough, pleuritic pain and fever. A CT Scan thorax revealed a left lower lobe mass with left pleural and pericardial effusion and mediastinal lymph nodes. Similarly, the PET scan showed various fluorodeoxyglucose (FDG)-positron uptake in these areas. However the lung mass biopsy cultured Burkholderia pseudomallei concurrently with a Melioidosis serology titre of >1:1024. He responded to intravenous Meropenem followed by Co-Trimoxazole and Doxycycline over the course of 21 weeks, ultimately leading to the resolution of any significant radiological findings.