Short-term outcomes of different esophagojejunal anastomotic techniques during laparoscopic total gastrectomy: a network meta-analysis.

BACKGROUND: Different techniques have been described for esophagojejunostomy (EJ) during laparoscopic total gastrectomy (LTG) for gastric cancer. Linear stapled techniques include overlap (OL) and functional end-to-end anastomosis (FEEA) while single staple technique (SST), hemi-double staple technique (HDST), and OrVil® are circular stapled approaches. Nowadays, the choice among techniques for EJ depends on operating surgeon personal preference. PURPOSE: To compare short-term outcomes of different EJ techniques during LTG. METHODS: Systematic review and network meta-analysis. OL, FEEA, SST, HDST, and OrVil® were compared. Primary outcomes were anastomotic leak (AL) and stenosis (AS). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to measure relative inference. RESULTS: Overall, 3177 patients (20 studies) were included. The technique for EJ was SST (n = 1026; 32.9%), OL (n = 826; 26.5%), FEEA (n = 752; 24.1%), OrVil® (n = 317; 10.1%), and HDST (n = 196; 6.4%). AL was comparable for OL vs. FEEA (RR = 0.82; 95% CrI 0.47-1.49), OL vs. SST (RR = 0.55; 95% CrI 0.27-1.21), OL vs. OrVil® (RR = 0.54; 95% CrI 0.32-1.22), and OL vs. HDST (RR = 0.65; 95% CrI 0.28-1.63). Similarly, AS was similar for OL vs. FEEA (RR = 0.46; 95% CrI 0.18-1.28), OL vs. SST (RR = 0.89; 95% CrI 0.39-2.15), OL vs. OrVil® (RR = 0.36; 95% CrI 0.14-1.02), and OL vs. HDST (RR = 0.61; 95% CrI 0.31-1.21). Anastomotic bleeding, time to soft diet resumption, pulmonary complications, hospital length of stay, and mortality were comparable while operative time was reduced for FEEA. CONCLUSIONS: This network meta-analysis shows similar postoperative AL and AS risk when comparing OL, FEEA, SST, HDST, and OrVil® techniques. Similarly, no differences were found for anastomotic bleeding, operative time, soft diet resumption, pulmonary complications, hospital length of stay and 30-day mortality.

Techniques for reconstruction after distal gastrectomy for cancer: updated network meta-analysis of randomized controlled trials.

BACKGROUND: The choice of the best reconstruction technique after distal gastrectomy (DG) remains controversial and still not defined. The purpose was to perform a comprehensive evaluation within the major type of intestinal reconstruction after DG for gastric cancer. METHODS: Systematic review and network meta-analyses of randomized controlled trials (RCTs) to compare Billroth I (BI), Billroth II (BII), Billroth II Braun (BII Braun), Roux-en-Y (RY), and Uncut Roux-en-Y (URY). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures while 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Ten RCTs (1456 patients) were included. Of these, 448 (33.7%) underwent BI, 220 (15.1%) BII, 114 BII Braun (7.8%), 533 (36.6%) RY, and 141 URY (9.6%). No significant differences were found among treatments for 30-day mortality, anastomotic leak, anastomotic stricture, and overall complications. At 12-month follow-up, RY was associated with a significantly reduced risk of remnant gastritis compared to BI (RR=0.56; 95% Crl 0.35-0.76) and BII reconstruction (RR=0.47; 95% Crl 0.22-0.97). Similarly, despite the lack of statistical significance, RY seems associated with a trend toward reduced endoscopically proven esophagitis compared to BI (RR=0.58; 95% Crl 0.24-1.51) and bile reflux compared to BI (RR=0.48; 95% Crl 0.17-1.41), BII (RR=0.74; 95% Crl 0.20-2.81), and BII Braun (RR=0.65; 95% Crl 0.30-1.43). CONCLUSIONS: This network meta-analysis shows that there are five main options for intestinal anastomosis after DG. All techniques seem equally safe with comparable anastomotic leak, anastomotic stricture, overall morbidity, and short-term outcomes. In the short-term follow-up (12 months), RY seems associated with a reduced risk of remnant gastritis and a trend toward a reduced risk of bile reflux and esophagitis.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis.

BACKGROUND: Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS: Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). CONCLUSIONS: LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes.

BACKGROUND: Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm2, a mesh is used to reinforce the repair. OBJECTIVE: The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes. METHODS: Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed. RESULTS: Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm2 while 26 patients had an HSA greater than 4 cm2. The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved. CONCLUSIONS: The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.

Treatment of Inguinal Hernia: Systematic Review and Updated Network Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Despite the advent of innovative surgical platforms and operative techniques, a definitive indication of the best surgical option for the treatment of unilateral primary inguinal hernia remains unsettled. Purpose was to perform an updated and comprehensive evaluation within the major approaches to inguinal hernia. METHODS: Systematic review and network meta-analyses of randomized controlled trials (RCTs) compare Lichtenstein tension-free repair, laparoscopic transabdominal preperitoneal (TAPP) repair, and totally extraperitoneal repair (TEP). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Thirty-five RCTs (7777 patients) were included. Overall, 3496 (44.9%) underwent Lichtenstein, 1269 (16.3%) TAPP, and 3012 (38.8%) TEP repair. The Visual Analogue Scale (VAS) was significantly lower for minimally invasive repair at <12 hours, 24 hours, and 48 hours. Postoperative chronic pain [TAPP vs Lichtenstein (RR = 0.36; 95% CrI 0.15-0.81) and TEP vs Lichtenstein (RR = 0.36; 95% CrI 0.21-0.54)] and return to work/activities [TAPP vs Lichtenstein (WMD = -3.3; 95% CrI -4.9 to -1.8) and TEP vs Lichtenstein (WMD = -3.6; 95% CrI -4.9 to -2.4)] were significantly reduced for minimally invasive approaches. Wound hematoma and infection were significantly reduced for minimally invasive approaches, whereas no differences were found for seroma, hernia recurrence, and hospital length of stay. CONCLUSIONS: Minimally invasive TAPP and TEP repair seem associated with significantly reduced early postoperative pain, return to work/activities, chronic pain, hematoma, and wound infection compared to the Lichtenstein tension-free repair. Hernia recurrence, seroma, and hospital length of stay seem similar across treatments.

Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis.

INTRODUCTION: The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer. MATERIALS AND METHODS: Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted. RESULTS: Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0-22.0%), 1.4% (95% CI = 0.8-2.2%), 35% (95% CI = 20.0-54.0%), and 5.0% (95% CI = 3.0-8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0-21.6%). CONCLUSIONS: Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.

Magnetic sphincter augmentation device removal: surgical technique and results at medium-term follow-up.

BACKGROUND: The magnetic sphincter augmentation (MSA) device has become a common option for the treatment of gastroesophageal reflux disease (GERD). Knowledge of MSA-related complications, indications for removal, and techniques are puzzled. With this study, we aimed to evaluate indications, techniques for removal, surgical approach, and outcomes with MSA removal. METHODS: This is an observational singe-center study. Patients were followed up regularly with endoscopy, pH monitoring, and assessed for specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and generic short-form 36 (SF-36) quality of life. RESULTS: Five patients underwent MSA explant. Four patients were males and the median age was 47 years (range 44-55). Heartburn, epigastric/chest pain, and dysphagia were commonly reported. The median implant duration was 46 months (range 31-72). A laparoscopic approach was adopted in all patients. Intraoperative findings included normal anatomy (40%), herniation in the mediastinum (40%), and erosion (20%). The most common anti-reflux procedures were Dor (n = 2), Toupet (n = 2), and anterior partial fundoplication (n = 1). The median operative time was 145 min (range 60-185), and the median hospital length of stay was 4 days (range 3-6). The median postoperative follow-up was 41 months (range 12-51). At the last follow-up, 80% of patients were off PPI; the GERD-HRQL and SF-36 questionnaire were improved with DeMeester score and esophageal acid exposure normalization. CONCLUSION: The MSA device can be safely explanted through a single-stage laparoscopic procedure. Tailoring a fundoplication, according to preoperative patient symptoms and intraoperative findings, seems feasible and safe with a promising trend toward improved symptoms and quality of life.

Laparoscopic Toupet Fundoplication for the Treatment of Laryngopharyngeal Reflux: Results at Medium-Term follow-Up.

BACKGROUND: The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up. MATERIALS AND METHODS: Observational cohort study (2015-2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) validate questionnaires at baseline and during follow-up. RESULTS: Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR-HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores "voice," "cough," "throat" and "swallow" showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved (p < 0.001). CONCLUSIONS: LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients' quality of life perception up to 3-year follow-up.

Minimally-Invasive Myotomy: Percutaneous Laparoscopic Surgical Approach for Achalasia.

The laparoscopic approach of the upper gastrointestinal tract is considered the gold standard for the treatment of functional benign esophageal disorders since 1990. In recent years, many efforts have been made to minimize the abdominal wall's trauma to reduce postoperative pain and to obtain a prompt return to daily activities, as well as improve cosmetic results of surgery. The progressive development of novel surgical devices has allowed for the introduction of new minimally-invasive surgical techniques. Criticism of the single-incision laparoscopic surgery includes a modification of surgical technique and an increased incidence of wound-related complications, such as infections and incisional hernia. We present our early experience using the new MiniLap® Percutaneous Surgical System (Teleflex Incorporated, Wayne, Pennsylvania) to perform a two-trocars laparoscopic percutaneous-assisted esophageal Heller myotomy. We demonstrate that the use of percutaneous instruments was not inferior in terms of clinical outcomes as compared to the standard technique, while improving cosmetic results and reducing trocar-related abdominal pain.

A Complete Sutureless, Hernia Repair for Primary Inguinal Hernia The Trabucco Repair: A Tribute to Ermanno Trabucco.

Since 1989, the authors have been using the Trabucco tension-free and sutureless technique for the repair of primary groin hernia with a pre-shaped mesh in more than 8,000 surgical procedures for complex and "simple" abdominal and inguinal hernias; over 4,000 cases have been considered in this study. The great majority of these procedures were performed under local anaesthesia and with a complete and careful nerve sparing. Compared to the Lichtenstein's technique, which is currently the golden standard treatment worldwide, there are no significant differences in the observed recurrence rate (below 2%). For the Law of Pascal, the pre-shaped prosthesis developed by Trabucco remains stretched uniformly in the inguinal canal, without the need to be secured with sutures and without forming dead space, which is a cause of infections, pain, and recurrence. The main advantage of a tension-free and sutureless repair is given by the relevant reduction in postoperative chronic neuralgia, which is not an uncommon complication and, depending on its intensity, can also potentially jeopardize a patient's work and social activities. The identification and the sparing of the three nerves of the inguinal region is of crucial importance to reduce the rate of neuralgia in the short and long term. Furthermore, the use of a local anaesthesia imposes the surgeon to properly recognize those nerves and to respect them during the repair. It goes without saying that the complete exposition of the right anatomy of inguinal canal is mandatory. The intentional section of one or more nerves, when it is not technically possible to achieve a satisfactory nerve sparing, or special tricks to create proper fenestrations (small window) on the edge of the prosthesis to prevent the scar tissue to involve the spared nerves, ensures a further reduction of the rate of neuralgia and excellent patient outcomes.

Pubic inguinal pain syndrome: the so-called sports hernia.

The "sportsman's hernia" commonly presents as a painful groin in those sports that involve kicking and twisting movements while running, particularly in rugby, football, soccer, and ice hockey players. Moreover, sportsman's hernia can be encountered even in normally physically active people. The pain experienced is recognized at the common point of origin of the rectus abdominis muscle and the adductor longus tendon on the pubic bone and the insertion of the inguinal ligament on the pubic bone. It is accepted that this chronic pain caused by abdominal wall weakness or injury occurs without a palpable hernia. We proposed the new name "pubic inguinal pain syndrome." In the period between January 2006 and November 2013 all patients afferent in our ambulatory clinic for chronic groin pain without a clinically evident hernia were assessed with medical history, physical examination, dynamic ultrasound, and pelvic and lumbar MRI. All patients were proposed for a conservative treatment and then, if it was not effective, for a surgical treatment. Our etiopathogenetic theory is based on three factors: (1) the compression of the three nerves of the inguinal region, (2) the imbalance in strength of adductor and abdominal wall muscles caused by the hypertrophy and stiffness of the insertion of rectus muscle and adductor longus muscle, and (3) the partial weakness of the posterior wall. Our surgical procedure includes the release of all three nerves of the region, the correction of the imbalance in strength with the partial tenotomy of the rectus and adductor longus muscles, and the repair of the partial weakness of the posterior wall with a lightweight mesh. This treatment reported excellent results with complete relief of symptoms after resumption of physical activity in all cases.

Long-Term Impact of D2 Lymphadenectomy during Gastrectomy for Cancer: Individual Patient Data Meta-Analysis and Restricted Mean Survival Time Estimation.

BACKGROUND: Debate exists concerning the impact of D2 vs. D1 lymphadenectomy on long-term oncological outcomes after gastrectomy for cancer. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched and randomized controlled trials (RCTs) analyzing the effect of D2 vs. D1 on survival were included. Overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were assessed. Restricted mean survival time difference (RMSTD) and 95% confidence intervals (CI) were used as effect size measures. RESULTS: Five RCTs (1653 patients) were included. Overall, 805 (48.7%) underwent D2 lymphadenectomy. The RMSTD OS analysis shows that at 60-month follow-up, D2 patients lived 1.8 months (95% CI -4.2, 0.7; p = 0.14) longer on average compared to D1 patients. Similarly, 60-month CSS (1.2 months, 95% CI -3.9, 5.7; p = 0.72) and DFS (0.8 months, 95% CI -1.7, 3.4; p = 0.53) tended to be improved for D2 vs. D1 lymphadenectomy. CONCLUSIONS: Compared to D1, D2 lymphadenectomy is associated with a clinical trend toward improved OS, CSS, and DFS at 60-month follow-up.

Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis.

BACKGROUND: Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain. AIM: To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence. RESULTS: Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low. CONCLUSIONS: This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.

Is previous radical prostatectomy a contraindication to minimally invasive inguinal hernia repair? A contemporary meta-analysis.

INTRODUCTION: Traditionally, radical prostatectomy (RP) has been considered a contraindication to minimally invasive inguinal hernia repair. Purpose of this systematic review was to examine the current evidence and outcomes of minimally invasive inguinal hernia repair after RP. MATERIALS AND METHODS: Web of Science, PubMed, and EMBASE data sets were consulted. Laparoscopic transabdominal preperitoneal repair (TAPP), robotic TAPP (r-TAPP), and totally extraperitoneal (TEP) repair were included. RESULTS: Overall, 4655 patients (16 studies) undergoing TAPP, r-TAPP, and TEP inguinal hernia repair after RP were included. The age of the patients ranged from 35 to 85 years. Open (49.1%), laparoscopic (7.4%), and robotic (43.5%) RP were described. Primary unilateral hernia repair was detailed in 96.3% of patients while 2.8% of patients were operated for recurrence. The pooled prevalence of intraoperative complication was 0.7% (95% CI 0.2-3.4%). Bladder injury and epigastric vessels bleeding were reported. The pooled prevalence of conversion to open was 0.8% (95% CI 0.3-1.7%). The estimated pooled prevalence of seroma, hematoma, and surgical site infection was 3.2% (95% CI 1.9-5.9%), 1.7% (95% CI 0.9-3.1%), and 0.3% (95% CI = 0.1-0.9%), respectively. The median follow-up was 18 months (range 8-48). The pooled prevalence of hernia recurrence and chronic pain were 1.1% (95% CI 0.1-3.1%) and 1.9% (95% CI 0.9-4.1%), respectively. CONCLUSIONS: Minimally invasive inguinal hernia repair seems feasible, safe, and effective for the treatment of inguinal hernia after RP. Prostatectomy should not be necessarily considered a contraindication to minimally invasive inguinal hernia repair.

What is the ideal mesh location for incisional hernia prevention during elective laparotomy? A network meta-analysis of randomized trials.

BACKGROUND: Incisional hernia (IH) represents an important complication after surgery. Prophylactic mesh reinforcement (PMR) with different mesh locations [onlay (OL), retromuscular (RM), preperitoneal (PP), and intraperitoneal (IP)] has been described to possibly reduce the risk of postoperative IH. However, data reporting the 'ideal' mesh location are sparse. The aim of this study was to evaluate the optimal mesh location for IH prevention during elective laparotomy. METHODS: Systematic review and network meta-analysis of randomized controlled trials (RCTs). OL, RM, PP, IP, and no mesh (NM) were compared. The primary aim was postoperative IH. Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. RESULTS: Fourteen RCTs (2332 patients) were included. Overall, 1052 (45.1%) had no mesh (NM) while 1280 (54.9%) underwent PMR stratified in IP ( n =344 pts), PP ( n =52 pts), RM ( n =463 pts), and OL ( n =421 pts) placement. Follow-up ranged from 12 months to 67 months. RM (RR=0.34; 95% CrI: 0.10-0.81) and OL (RR=0.15; 95% CrI: 0.044-0.35) were associated with significantly reduced IH RR compared to NM. A tendency toward reduced IH RR was noticed for PP versus NM (RR=0.16; 95% CrI: 0.018-1.01), while no differences were found for IP versus NM (RR=0.59; 95% CrI: 0.19-1.81). Seroma, hematoma, surgical site infection, 90-day mortality, operative time and hospital length of stay were comparable among treatments. CONCLUSIONS: RM or OL mesh placement seems associated with reduced IH RR compared to NM. PP location appears promising; however, future studies are warranted to corroborate this preliminary indication.

C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis.

BACKGROUND: Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery. METHODS: Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD). RESULTS: Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7-9%), and the median time to diagnosis was 6.9 days (range 3-10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23-0.85), 0.84 (95% CIs 0.18-0.86) and 0.84 (95% CIs 0.18-0.89) respectively. Negative likelihood ratios (LR-) showed moderate evidence to rule out AL on POD 3 (LR- 0.29), POD4 (LR- 0.24) and POD5 (LR- 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (-0.18) showed moderate evidence to rule out AL. CONCLUSIONS: In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.

Reducing postoperative pain: the use of Tisseel for mesh fixation in inguinal hernia repair.

INTRODUCTION: The new objective in primary hernia surgery should be the reduction of disabling chronic pain. This article will discuss the safety, efficacy, and reduction of pain of a sutureless glue mesh procedure for primary uncomplicated inguinal hernia repair. METHODS: We began performing sutureless glue mesh repairs in 2004 for primary uncomplicated inguinal hernias with good results. After reduction of the hernia sac, polypropylene medium-weight preshaped flat mesh is fixed to the posterior inguinal wall with 0.5 mL of fibrin glue on the pubic tubercle; another 1.5 mL is sprayed on the entire mesh surface. The cord is positioned in subcutaneous space. The TI.ME.LI (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair) trial was planned and conducted based on this experience. RESULTS: In two years, we treated more than 600 primary inguinal hernias with fibrin glue mesh fixation repair. At follow-up (2 to 96 months after surgery), no patients presented with severe pain, 2.7% of patients complained of moderate pain. CONCLUSION: Fibrin sealant for mesh fixation in open repair is well tolerated and it should be considered as a first-line option for mesh fixation in open inguinal hernia repair.

Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis.

BACKGROUND: In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival. METHODS: Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures. RESULTS: Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy. CONCLUSION: For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR. MATERIALS AND METHODS: Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures. RESULTS: Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31-0.88), staple line leak (RR=0.56; 95% CrI 0.32-0.99), and overall complications (RR=0.50; 95% CrI 0.30-0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8-21.7), GR (WMD=15.0; 95% CrI 7.7-22.4), and GoR (WMD=15.5; 95% CrI 5.6-25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality. CONCLUSIONS: SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted.