Operative approaches and outcomes of nephroureterectomy for UTUC: a network meta-analysis.

Roux-en-Y gastric bypass: systematic review and Bayesian network meta-analysis comparing open, laparoscopic, and robotic approach

Ventral hernia repair is one of the most frequently performed surgical procedures worldwide, yet there is no consensus on the safest and most effective approach. This network meta-analysis aimed to evaluate the optimal surgical technique for ventral hernia repair. We systematically searched PubMed, Embase, and Cochrane for randomized controlled trials comparing surgical interventions for ventral hernia repair. A frequentist network meta-analysis was conducted, pooling risk ratios for binary outcomes and mean differences for continuous outcomes with 95% CIs. A total of 34 studies with 3,779 patients were included. No significant differences were observed in recurrence, seroma, or hematoma rates between groups. Laparoscopic intraperitoneal onlay mesh plus significantly reduced hospital stays compared with open surgery (mean difference -2.24 days; 95% CI -3.26 to -1.23) and wound infection risk (risk ratio 0.29; 95% CI 0.21 to 0.41) compared with open surgery. The robotic approach was associated with increased operative time compared with both laparoscopic and open approaches (mean difference -49.08 minutes; 95% CI -87.77 to -10.39). Laparoscopic and robotic techniques demonstrated similar efficacy in recurrence, seroma, and hematoma rates. Although open surgery remains a more cost-effective approach, it was associated with a higher risk of wound infections. Given these findings, the choice of surgical technique should be individualized based on patient-specific factors, surgeon expertise, and institutional resources to optimize both clinical and economic outcomes.

Esophageal cancer remains a leading cause of cancer-related mortality worldwide. Esophagectomy is the cornerstone of curative treatment, but the optimal surgical approach remains debated. Newer techniques such as hybrid esophagectomy, minimally invasive esophagectomy (MIE), and robot-assisted minimally invasive esophagectomy (RAMIE) have been developed to improve perioperative outcomes while maintaining oncologic efficacy. We aim to compare the effects of open, hybrid, minimally invasive, and robot-assisted approaches to esophagectomy on survival and perioperative outcomes in patients with esophageal cancer. A systematic review and network meta-analysis (NMA) were conducted, including 10 reports from 6 randomized controlled trials identified via PubMed, Cochrane Library, Embase, CINAHL, ClinicalTrials.gov, and ICTRP. Comparative analyses between open esophagectomy (OE), hybrid laparoscopy-thoracotomy (HYB LapS-ThoT), MIE, and RAMIE were performed using random-effects NMA models. Hazard ratios (HR), odds ratios (OR), and mean differences (MD) were calculated for outcomes. There were no significant differences in overall survival among OE, HYB LapS-ThoT, MIE, and RAMIE. Pulmonary complications were significantly lower with MIE (OR 0.47, 95% CI 0.33-0.69, p<0.0001) and RAMIE (OR 0.39, 95% CI 0.27-0.57, p<0.0001) compared to OE. RAMIE yielded a higher lymph node harvest (MD 1.56, 95% CI 0.58-2.54, p=0.002) and lower reoperation rates (OR 0.65, 95% CI 0.45-0.93, p=0.020) than OE. HYB LapS-ThoT was associated with increased anastomotic leakage compared to OE (OR 1.66, 95% CI 1.02-2.69, p=0.041). MIE and RAMIE significantly reduce pulmonary complications without compromising survival. Hybrid approaches appear to increase the risk of anastomotic leakage. These findings support minimally invasive techniques, especially RAMIE; however, more evidence and further studies are needed to allow for a clearer and more definitive conclusion.

Introduction: Patients who sustained thoracolumbar spine fracture without neurological deficit often require surgical treatment. The conventional open posterior approach had some disadvantages including post-operative pain, blood loss, and duration of the operation. The minimally invasive approach, open muscle-preserving pedicle screw fixation, was proposed to have more benefit than the conventional approach. This study evaluated the clinical and perioperative outcomes of thoracolumbar burst fracture fixation using the open muscle-preserving approach and the conventional open posterior approach. Methods: A prospective cohort study from June 2016 to June 2017 of the open muscle-preserving pedicle screw fixation approach was done compared to the historical control of the conventional open posterior approach from May 2015 to May 2016. The post-operative pain score, blood loss, duration of operation and clinical outcome were analyzed. Results: Twenty-three patients were enrolled in the muscle-preserving approach group, and 27 patients treated with the conventional open posterior approach were the control group. Post-operative VAS was significantly better in the muscle-preserving group (P&lt;0.001). The mean operating time was significantly shorter in the muscle-preserving group (60.4±17.3 min. vs. 90.9±18.9 min., p&lt;0.001). Moreover, the mean intra-operative blood loss of the muscle-preserving group was also significantly lower (156.96±96.3ml. vs. 269.26±147.6ml., p=0.003). Conclusion: Our study results indicate a superiority of the open muscle-preserving approach over the conventional open posterior approach for a thoracolumbar burst fracture without neurologic injury in terms of post-operative pain score, blood loss and duration of operation. The open muscle-preserving approach is an alternative treatment for thoracolumbar burst fractures.

Long-term outcomes for hybrid aortic arch repair

Total mesorectal excision (TME) for rectal cancer can be achieved by employing open (OpTME), laparoscopic (LaTME) and robotic (RoTME) approaches but which of these has the best outcome?The aim of present study is to identify the most effective technique for rectal cancer by comparing all outcomes. Randomized controlled trials (RCTs) which compared at least two TME strategies were identified by literature search of electronic databases of articles published to June 2018. Network meta-analysis with trial sequential analysis was performed using a frequentist approach with random-effects meta-analysis. Data collection and analysis We conducted a systematic search of PubMed, EmBase, the Cochrane Library, CNKI, and Web of Science.Titles and abstracts of the retrieved publications were independently and blindly assessed by two authors. Twenty-two RCTs with 4882 rectal cancer patients were included in this analysis. The trial sequential analysis demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundaries, suggesting that OpTME resulted in a more complete TME specimen than LaTME (relative risk 1.05, 95% confidence interval 1.01-1.08). Network meta-analysis showed there was no significant difference in the other comparisons. Based on the P score of completeness of the TME specimen and circumferential resection margin positivity, the best technique was OpTME, followed by RoTME and then LaTME. However, this order was reversed when complications and mortality were considered. RoTME led to better lymph node harvest. Although OpTME may give better pathological specimens, minimally invasive techniques may have advantages when considering lymph node harvest, complications and mortality. More RCTs are needed to determine which technique actually gives the best chance of survival.

Outcomes of operations for benign foregut disease in elderly patients: A National Surgical Quality Improvement Program database analysis

AimThe optimum surgical approach to splenic flexure cancers (SFCs) remains uncertain. The aim of this survey was to explore the opinions of an international surgical community on the management and outcomes of SFC.MethodA questionnaire was constructed comprising five sections (information about respondents; definition and prognosis of SFC; operative approach; approach in specific scenarios; outcomes) and circulated through an international dissemination committee and social media.ResultsThe survey received 576 responses over 4 weeks across 50 countries. There was no consensus regarding the definition of the splenic flexure, whilst the proportion of respondents who did and did not think that patients with SFC had a worse outcome was equal. The overall preferred operative approach was left hemicolectomy [203 (35.2%)], followed by segmental resection [167 (29%)], extended right hemicolectomy [126 (21.9%)] and subtotal colectomy [7 (12%)]. The stated pedicles for ligation varied between resection types and also within the same resection. One hundred and sixty‐six (28.8%) respondents thought a segmental resection was associated with the worst survival and 190 (33%) thought it was associated with the best quality of life.ConclusionThis survey confirms a lack of consensus across all aspects SFC treatment. The differing approaches described are likely to represent different beliefs around the variable anatomy of this region and the associated lymphatic drainage. Future studies are required to address such inconsistencies and identify the optimum surgical strategy, whilst also incorporating quality‐of‐life metrics and patient‐reported outcomes. A one‐size‐fits‐all approach is probably not appropriate with SFC, and a more bespoke approach is required.

Objective: Surgical site infection (SSI) is one of the most common healthcare-associated infections. This study aimed to determine SSI rate and the associated factors among colorectal surgery patients. Methods: This included adult patients who underwent surgery under the Division of Colorectal Surgery from January to May 2018. Clinico-demographic, operative, and SSI outcome data were reviewed. Occurrence of SSI during admission until discharge, and up to 30 days after the surgery was analyzed. Results: A total of 172 surgeries were performed. Majority were elective procedures (68.0%) and performed via open approach (67.4%). Most were malignant cases (62.6%). Sixty-three colorectal resections were done (41 colon and 22 rectal). SSI rate prior to discharge was 6.4%, and15.7% at 30 days. Among colorectal resections, 18 (28.6%) patients had SSI at 30 days. SSI rates were significantly higher among patients who were ASA 2 or 3; received chemotherapy 12 weeks prior to surgery; had malignant pathology; underwent emergency surgery; received perioperative transfusion; had stapled skin closure; had low anterior resection for rectal cancer; and had multivisceral resection. Conclusion: The Division of Colorectal Surgery at the Philippine General Hospital had a higher SSI rate as compared to literature. Although this could be partly explained by the differences in patient and surgeon population, improving on SSI rates will be the unit’s goal. Continued SSI surveillance with more patient accrual may provide better insight to the associated risk factors. Key words: Surgical site infection, colorectal surgery, risk factors

After comparing with open approach, left lateral sectionectomy (LLS) has become standard in terms of short-term outcomes without jeopardizing long-term survival when performed for malignancy. The aim of this study was to compare the short-term and economic outcomes of laparoscopic (L-LLS) and robotic (R-LLS) LLS. All consecutive patients who underwent L-LLS or R-LLS from 1997 to 2014 were analyzed. Short-term and economic outcomes were compared between the two groups using a propensity score matching (PSM). Ninety-six consecutive cases of LLS were performed using the laparoscopic (80 cases; 83%) or robotic (16 cases; 17%) approach. The two groups were similar for operative and surgical outcomes. Operation time was similar in the R-LLS compared to the L-LLS group (190 vs. 162min; p=0.10). Perioperative costs were higher (1457 € vs. 576 €; p<0.0001) in the R-LLS group than in the L-LLS group; however, postoperative costs were similar between the two groups (4065 € in the R-LLS group vs. 5459 € in the L-LLS group; p=0.30). Total costs were similar between the two groups (5522 € in the R-LLS group vs. 6035€ in the L-LLS group; p=0.70). The PSM included 14 patients for each group. Surgical and economic outcomes remained similar after PSM, except for total operating time which was significantly longer in the R-LLS group than in the L-LLS group. Even if feasible and safe, the robotic approach does not seem so far to offer additional benefit in terms of intra- and postoperative outcomes over the laparoscopic approach in patients requiring LLS. Total costs associated with the R-LLS group are not greater than that associated with the L-LLS group, which is the standard of care so far.

Background: The surgical approach and choice of drainage veins for uterus transplantation living-donor surgery have been investigated to reduce invasiveness. Methods: A thorough search of the PubMed database was conducted. The search was not limited by language or date of publication. The data were collected on 13 October 2020. Two reviewers independently assessed each article and determined eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed articles reporting surgical information or postoperative course, articles regarding animal research on UTx, UTx on deceased donors, or not original articles. Results: Of the 51 operations within 26 articles reviewed, the mean operative time was shortest in the laparoscopic approach, and longest in the robot-assisted approach. The mean blood loss was less in the laparoscopic and robot-assisted approaches than in the open approach. In cases where the uterine veins were not preserved, the mean operative time was shortened by each approach and the mean blood loss decreased with the laparoscopic and robot-assisted approaches. Conclusions: These procedures may contribute to less invasive living-donor surgery.

Gastroesophageal reflux disease (GERD) is common, and the outcomes of primary laparoscopic antireflux surgery are excellent. A minority of individuals will present with recurrent symptoms, typically of GERD or dysphagia, and seek revisional surgery. Herein is a discussion of the most common presentations and etiologies of failed antireflux surgery. In addition, the preoperative assessment and diagnostic tests utilized in the workup of this population are reviewed. Finally, the operative approach and outcomes related to performing revision laparoscopic antireflux surgery are examined including the use of Roux-en-Y gastric bypass in this patient population.

American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality. This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival. The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013). Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.

Plexiform neurofibromas with sizable intraspinal extensions and resultant spinal cord compromise pose challenging management problems, because these lesions may involve multiple nerves and engulf adjacent vascular and visceral structures. In this report, we review our experience with the surgical treatment of these lesions. Patients were identified by a detailed review of hospital medical records and the database of our multidisciplinary neurofibromatosis clinic. Ten patients had large plexiform neurofibromas that extended intraspinally, producing a combination of myelopathy and radiculopathy. Two patients exhibited single-level intraspinal growth, and eight showed multilevel involvement. Four patients showed bilateral plexiform neurofibromatous growth intraspinally, with "hourglass" compression of the spinal cord. Operative approaches and outcomes were reviewed in detail. Gross total resection of the symptomatic intraspinal tumor component was achieved for nine patients. The management of the extraspinal component was individualized, depending on the pattern and extent of involvement of the surrounding structures. Nine patients experienced complete recovery of neurological function postoperatively; the remaining patient demonstrated significant functional improvement. With a median follow-up period of 4 years, only one patient has developed recurrent intraspinal compression, in this case from tumor involvement by the same plexiform lesion at a lower spinal level. Two patients treated early in the series using standard laminectomy approaches developed significant kyphotic deformities, necessitating subsequent fusion. Based on these initial results, osteoplastic laminotomy techniques were used in the last five cases, allowing anatomic reconstruction of the involved levels; none of these latter patients has developed significant kyphosis, with a median follow-up period of 3 years. Radical resection of intraspinal tumor components in patients with neurofibromatosis 1 and large plexiform neurofibromas can help to preserve excellent neurological function. Technical factors in the management of these lesions are presented.

The efficacy of laparoscopic simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases (SCRLM) remains unclear. We retrospectively evaluated data from 258 patients who had undergone simultaneous curative resection of the primary tumor and SCRLM from 2006 to 2017. We compared surgical outcomes between open, hybrid (laparoscopic colorectal resection and open hepatectomy), and pure laparoscopic approaches. Surgical outcomes were also evaluated between the open hepatectomy (OH) group (ie, open/hybrid surgery) and the laparoscopic hepatectomy (LH) group (ie, pure laparoscopic surgery) in 141 patients later in the study period (2013-2017), when the clinical indications for laparoscopic hepatectomy were restricted to simple wedge resection and/or left lateral sectionectomy in our center. The pure laparoscopic approach was associated with significantly less intraoperative blood loss and a significantly shorter postoperative hospital stay than the open and hybrid approaches. Late in the study period, operative outcomes in the LH group (n = 37) were more favorable than for the OH group (n = 104) in terms of intraoperative blood loss and postoperative hospital stay. In patients with rectal cancer, however, earlier postoperative recovery in the LH group did not differ significantly from the OH group. Laparoscopic simultaneous resection of SCRLM with the primary tumor by simple hepatectomy is safe and may enhance patients' postoperative recovery, especially in patients with colon cancer.