Comprehensive review of hepatocellular carcinoma with portal vein tumor thrombus: State of art and future perspectives

BACKGROUND

Despite advances in the diagnosis of patients with hepatocellular carcinoma (HCC), 70%-80% of patients are diagnosed with advanced stage disease. Portal vein tumor thrombus (PVTT) is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.

DATA SOURCES

A systematic search of MEDLINE (PubMed), Embase, Cochrane Library and Database for Systematic Reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases until December 2022 was conducted using free text and MeSH terms: hepatocellular carcinoma, portal vein tumor thrombus, portal vein thrombosis, vascular invasion, liver and/or hepatic resection, liver transplantation, and systematic review.

RESULTS

Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy. Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus, accurate identification of the subgroups of patients who may benefit from resection, as well as meticulous surgical technique. This review addressed five specific areas: (a) formation of PVTT; (b) classifications of PVTT; (c) controversies related to clinical guidelines; (d) surgical treatments versus non-surgical approaches; and (e) characterization of surgical techniques correlated with classifications of PVTT.

CONCLUSIONS

Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.

Colonic Perforation Secondary to Gallstone Impaction in the Sigmoid Colon

Introduction

Gallstone sigmoid ileus is a very rare manifestation of large bowel obstruction. Mainly, three conditions predispose the manifestation of the entity; in particular, an episode of cholecystitis causing cholecysto-colonic fistula; a large gallstone; and narrowing of the sigmoid colon secondary to diverticular disease or malignancy. Case Report. An 82-year-old man presented to the emergency department with a one-week history of severe constipation, tachypnoea, tachycardia, hypotension, and high lactate. Physical examination demonstrated cyanosed upper and lower extremities and palpation of the abdomen revealed signs of peritonism, abdominal distention, and guarding. Computerized tomography scan demonstrated perforation of the hollow viscus organ secondary to impaction of the large gallstone in the sigmoid colon. Laparotomy revealed sigmoid perforation and widespread feculent peritonitis. The patient underwent Hartmann's procedure. After the intervention gave concerns regarding the patient's haemodynamic stability, he was transferred to the intensive care unit. The patient passed away on the third postoperative day due to complications secondary to haemodynamic instability.

Conclusions

Patients with early diagnosed uncomplicated sigmoid gallstone ileus can be managed with endoscopic mechanical lithotripsy. In case of failure, open or laparoscopic enterolithotomy can be applied. However, when patients present with complications, surgery should not be delayed. In our case, Hartmann's procedure was an absolute indication due to sigmoid perforation and widespread feculent peritonitis.

Evaluation of the current guidelines for the management of haemorrhoidal disease using the Appraisal of Guidelines Research and Evaluation II instrument

Background

Haemorrhoids are a very common disease and many professional societies have produced guidelines for their treatment. The aim of this study is to appraise the quality of the existing guidelines in the management of haemorrhoids.

Methods

A systematic search of the literature was conducted in the EMBASE, Google Scholar, Cochrane library, and PubMed databases. The quality of guidelines was independently appraised using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument by five of the authors.

Results

Six guidelines of varying quality were identified and included in this study. The highest scoring guidelines were the SICCR (Società Italiana di Chirurgia Colorectale, which is Italian Society of Colorectal Surgery), ESCP (European Society of Coloproctology) and ASCRS (American Society of Colon and Rectal Surgeons) guidelines, scoring 86% each overall. There was considerable variability across not just the studies but across the different domains. The highest scoring domains were domain VI: editorial independence (median =95% across all studies) and domain I: Scope & Purpose (85%). The lowest scores were observed in domain V: Applicability (48%) and domain II: Stakeholder Involvement (41%). Only three of the six gained unanimous support for their use, whilst two of the guidelines were unanimously declared not suitable for clinical use.

Conclusions

With the notable exception of three guidelines (SICCR, ESCP and ASCRS), the general quality of haemorrhoid guidelines is poor. Stakeholder (especially patient) involvement and instructions on how to implement recommendations is lacking from the majority of guidelines. This is an area that requires urgent attention if we are to improve guidelines in haemorrhoid management.

Conservative Management of Mesenteric Panniculitis in a Remote Island

Introduction

Mesenteric panniculitis (MP) includes a spectrum of nonspecific fibroinflammatory disorders of unknown aetiology that affects mainly the root of the mesentery. Case Report. A 68-year-old man is incidentally diagnosed with MP during follow-up investigation for a fusiform coeliac artery aneurysm. Four years since the diagnosis, he is completely asymptomatic. After discussing with him and presenting the current evidence, he decided not to proceed with biopsy because the finding was incidental and he is asymptomatic. Moreover, tumour markers were within the normal range. He has been scheduled for annual follow-ups with computerized tomography (CT) scans and tumour markers.

Conclusions

MP is a rare chronic fibroinflammatory disease with contradictory evidence regarding its definition and management. Watchful follow-ups with CT scan and tumour markers are recommended for asymptomatic patients.

Alternatives to left lateral sector in paediatric liver transplantation-a systematic review on monosegmental and reduced grafts

Background

Paediatric liver transplantation (pLT) is the treatment of choice for many liver conditions. However, it still poses relevant challenges, mainly related to the size of the recipients. Unlike in adults, excessive graft volume might represent an issue when the estimated graft-recipient-weight-ratio (GRWR) is significantly disproportionate. In this situation, the traditional left lateral sector (LLS) grafts are too big and other alternatives are required, such as monosegmental or reduced (including hyper-reduced) grafts (RLLS/HRLLS). Results with conventional LLS-pLT are excellent and replicating them with monosegmental or RLLS is challenging given (I) the technical complexity and (II) the need to overcome the large-for-size scenario. This article is to review the existing experience with monosegmental, RLLS/HRLLS grafts and appraise its results.

Methods

Systematic search of the electronic databases, conducted from their inception until May 2020.

Results

After scrutiny of the available literature, 16 studies were included reporting 330 patients transplanted with monosegmental and RLLS/HRLLS grafts. There were 10 re-grafts (6 of them <90 days); 90% of grafts were LDLT. Overall, median recipient's age and weight were 7 months (range, 5 days-22 months) and 5.8 kg (range, 2.6-8 kg) respectively. Median graft weight was 209 grams (range, 124-264 grams) and median GRWR was 3.5% (range, 2.7-5.6%). Hepatic artery and portal vein thrombosis overall incidence were 1.5% and 4.2%; 120 out of the 330 pLT were monosegmental (37%) producing a smaller graft (median of 164 grams) and accordingly a lower GRWR (median 3.2%) compared to reduced LLS. With a median follow-up of 39 months (range, 6-87 months), the overall graft and patient survival were 84% (285/340) and 89% (295/330).

Discussion

Monosegmental and RLLS/HRLLS grafts provide access to liver transplantation for very small recipients with excellent results comparable to the standard LLS.

Making Emergency Surgical Decisions Without any Imaging Evidence: A Case Report of Complicated Diverticular Phlegmon

Acute left-sided diverticulitis is the third most common gastrointestinal disease after acute pancreatitis and cholecystitis requiring hospitalization. From those patients, 15% to 20% were diagnosed with abscess on the computed tomography (CT) scan. Usually, abscess larger than 5 cm are not amenable for medical treatment. A 61-year-old woman presented to emergency department of the general hospital in the remote island with 48-h history of fever, tachypnea, and tachycardia. Physical examination revealed 15 × 7 cm mass occupying the left mid-abdomen and iliac fossa. Patient did not report any unintentional loss of weight or change of bowel habits. She only reported that the last month she felt her lower tummy bloated. Due to absence of radiographer during this period in the hospital there was no possibility for any imaging investigations. Diagnostic laparoscopy revealed a phlegmon in the left abdomen consisting of the sigmoid colon, loops of the small bowel and wrapped by the omentum. Hartmann procedure was performed. Patient recovered uneventfully and was scheduled for reversal procedure. Surgical intervention is the treatment of choice for complicated large diverticular abscess; in the remote island, any delayed diagnosis may lead to life-threatening complications.

Navigated liver surgery: State of the art and future perspectives

BACKGROUND

In recent years, the development of digital imaging technology has had a significant influence in liver surgery. The ability to obtain a 3-dimensional (3D) visualization of the liver anatomy has provided surgery with virtual reality of simulation 3D computer models, 3D printing models and more recently holograms and augmented reality (when virtual reality knowledge is superimposed onto reality). In addition, the utilization of real-time fluorescent imaging techniques based on indocyanine green (ICG) uptake allows clinicians to precisely delineate the liver anatomy and/or tumors within the parenchyma, applying the knowledge obtained preoperatively through digital imaging. The combination of both has transformed the abstract thinking until now based on 2D imaging into a 3D preoperative conception (virtual reality), enhanced with real-time visualization of the fluorescent liver structures, effectively facilitating intraoperative navigated liver surgery (augmented reality).

DATA SOURCES

A literature search was performed from inception until January 2021 in MEDLINE (PubMed), Embase, Cochrane library and database for systematic reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases.

RESULTS

Fifty-one pertinent articles were retrieved and included. The different types of digital imaging technologies and the real-time navigated liver surgery were estimated and compared.

CONCLUSIONS

ICG fluorescent imaging techniques can contribute essentially to the real-time definition of liver segments; as a result, precise hepatic resection can be guided by the presence of fluorescence. Furthermore, 3D models can help essentially to further advancing of precision in hepatic surgery by permitting estimation of liver volume and functional liver remnant, delineation of resection lines along the liver segments and evaluation of tumor margins. In liver transplantation and especially in living donor liver transplantation (LDLT), 3D printed models of the donor's liver and models of the recipient's hilar anatomy can contribute further to improving the results. In particular, pediatric LDLT abdominal cavity models can help to manage the largest challenge of this procedure, namely large-for-size syndrome.

State of the Art, Current Perspectives, and Controversies of Budd-Chiari Syndrome: A Review

Background

Methods

Results

Conclusions

Combined Gluteal and Posterior Thigh Compartment Syndrome Without Associated Fracture: A Case Report

Compartment syndrome usually occurs after trauma, fracture, or compression injuries. To the authors’ best knowledge, this is the first reported case in the medical literature of a combined gluteal and posterior thigh compartment syndrome after an accidental fall without an associated fracture. A 65-year-old man attended the emergency department of the general hospital in a remote island complaining of a swollen painful thigh. He reported that 24 h previously he had an accidental slip and fall on his overstretching right leg. Physical examination revealed right posterior thigh edema, tenderness, paraesthesia, and firmness to palpation. Any attempt to flex the knee provoked pain of intensity 10/10. In addition, there was blue discoloration over the lower half of the gluteal region, non-compressible tense swelling, and pain of intensity 10/10 elicited with passive range of motion of the hip. Compartment syndrome was considered and consequently, fasciotomy of the gluteal and posterior thigh compartments was performed under spinal anesthesia. Compartment syndrome is a surgical emergency. In a remote island, it must be considered and treated early because any delayed diagnosis may lead to loss of an extremity, kidney failure, sepsis and even death.

Oral Bacterial Microbiota in Digestive Cancer Patients: A Systematic Review

The relation between the gut microbiota and human health is increasingly recognized. Recently, some evidence suggested that dysbiosis of the oral microbiota may be involved in the development of digestive cancers. A systematic review was conducted according to the PRISMA guidelines to investigate the association between the oral microbiota and digestive cancers. Several databases including Medline, Scopus, and Embase were searched by three independent reviewers, without date restriction. Over a total of 1654 records initially identified, 28 studies (2 prospective cohort studies and 26 case-controls) were selected. They investigated oral microbiota composition in patients with esophageal squamous cell carcinoma (n = 5), gastric cancer (n = 5), colorectal cancer (n = 9), liver carcinoma (n = 2), and pancreatic cancer (n = 7). In most of the studies, oral microbiota composition was found to be different between digestive cancer patients and controls. Particularly, oral microbiota dysbiosis and specific bacteria, such as Fusobacterium nucleatum and Porphyromonas gingivalis, appeared to be associated with colorectal cancers. Current evidence suggests that differences exist in oral microbiota composition between patients with and without digestive cancers. Further studies are required to investigate and validate oral-gut microbial transmission patterns and their role in digestive cancer carcinogenesis.

Appraisal of the Current Guidelines for Management of Malignant Left-Sided Colonic Obstruction Using the Appraisal of Guidelines Research and Evaluation II Instrument

INTRODUCTION

Colorectal cancer (CRC) is the fourth leading cause of death with 1.4 million new cases occurring annually worldwide. High-quality clinical practice guidelines are needed to tailor high-quality individualized treatment. The aim of the present study was to evaluate the methodological quality of the current guidelines for the management of acute malignant left-sided colonic bowel obstruction.

METHODS

A systematic search of the literature was carried out using electronic databases. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess the quality of each guideline.

RESULTS

Search results returned a total of 14 guidelines appropriate for assessment. Both domain I (scope and purpose) and domain VI (editorial independence) were assessed with the same median score of 83%. The lowest scoring domain was domain V (applicability), scoring only 43%. The 2 guidelines that had the highest score were the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), each scoring 100%. However, there were significant variations in terms of quality. The NICE and New Zealand guidelines were voted unanimously for use unchanged, whilst 8 other guidelines were voted for use with modifications.

CONCLUSION

Variation in guideline quality in CRC is a concern despite some clearly excellent published guidelines. All guidelines score poorly when it comes to describing how the guidelines could be applied. Lack of patient participation in guideline development is also a shortcoming that requires urgent redress.

A systematic review of the impact of portal vein pressure changes on clinical outcomes following hepatic resection

BACKGROUND

There are evolving data correlating elevated post-hepatic resection portal vein pressure (PVP) with risk of developing post-resection liver failure (PLF) and other complications. As a consequence, modulation of PVP presents a potential strategy to improve outcomes following liver resection (LR). The primary aim of this study was to review the existing evidence regarding the impact of post-resection PVP on clinical outcomes in patients undergoing a LR.

METHODS

Systematic literature searches of electronic databases in accordance with PRISMA were conducted. Changes in PVP and clinical outcomes following liver resection were defined according to the existing literature.

RESULTS

Ten studies, consisting of 712 patients with a median age 61 (52-68) years, were identified that met the inclusion criteria. Of those, 77% (n = 550) underwent a major LR and 27% (n = 195) of patients had cirrhosis. Following LR, the median (range) PVP increased from 11.4 mmHg (median baseline, range 7.3-16.4) to 15.9 mmHg (7.9-19). The overall median incidence of PLF was 19%. Six of the ten studies found an elevated PVP after LR predicted PLF. One study found elevated PVP after LR predicted mortality after LR.

CONCLUSION

Elevated PVP following hepatic resection was associated with increased rates of PLF. It was not possible to define a specific threshold PVP for predicting PLF. Modulation of PVP therefore presents a potential strategy to mitigate the incidence of LR. Future studies should standardize on reporting liver remnant and haemodynamics to better characterize clinical outcomes following LR.

Retroperitoneoscopic Standard or Hand-Assisted Versus Laparoscopic Standard or Hand-Assisted Donor Nephrectomy: A Systematic Review and the First Network Meta-Analysis

BACKGROUND

At the present four minimally invasive procedures namely retroperitoneoscopic (RPDN), laparoscopic (LPDN), hand-assisted retroperitoneoscopic (HARDN) and hand-assisted laparoscopic donor nephrectomy (HALDN) are used to perform donor nephrectomies. The current evidence based on retrospective studies and on pairwise only meta-analyses is inconclusive. Up to authors' best knowledge there is no so far network meta-analysis to compare all the above-mentioned procedures. Therefore, a network meta-analysis was conducted to compare the feasibility, safety and reproducibility of the four donor nephrectomies procedures.

METHODS

Google Scholar, EMBASE, PubMed, and Cochrane library were used for a systematic literature search. Both updated pairwise and network meta-analyses were performed.

RESULTS

Compared to LPDN there was evidence of significantly more right kidneys retrieved with RPDN; nonsignificant differences demonstrated both with HALDN and HARDN compared to LPDN. There was evidence that the operative time was significantly shorter by 77 min in RPDN compared to LPDN; on the other hand, HARDN and HALDN did not demonstrate significant differences when compared to LPDN.

CONCLUSIONS

The present study demonstrates that each approach can be applied safely in adequately selected patients. Moreover, retroperitoneoscopic is reliable, safe and easily reproducible alternative of LPDN for both left and right kidneys.

No difference in mortality among ALPPS, two-staged hepatectomy, and portal vein embolization/ligation: A systematic review by updated traditional and network meta-analyses

BACKGROUND

There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA).

DATA SOURCES

Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes.

RESULTS

Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort.

CONCLUSIONS

This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.

The Impact of COVID-19 Global Pandemic on Morbidity and Mortality of Liver Transplant Recipients Children and Adults: A Systematic Review of Case Series

The pandemic of coronavirus disease 2019 (COVID-19) changed the surgical everyday practice overnight. Currently, the first articles reporting outcomes of liver transplant recipients infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are published. The aim of the present study was to summarise the existing evidence of impact of COVID-19 global pandemic on liver transplant recipients. Electronic databases were searched in accordance with Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA). Five studies were selected from a pool of 12 studies with a total of 854 liver transplant recipients of whom 700 were children and the rest 154 were adults. The present evidence, based on case reports and series demonstrated lower mortality in liver transplant recipients compared to general population.

Recipient and allograft survival following donation after circulatory death versus donation after brain death for renal transplantation: A systematic review and meta-analysis

BACKGROUND-OBJECTIVES

Current evidence based on retrospective and prospective studies demonstrates that donation after circulatory death (DCD) grafts are more susceptible to delayed graft function (DGF) than donation after brain death (DBD) grafts. The short- and long-term survival outcomes of the two cohorts are unclear. Therefore, we performed a systematic review and meta-analysis to estimate the patient and allograft survival outcomes for DCD and DBD in renal transplant surgery.

METHODS

Systematic literature searches were conducted by searching various databases. Fixed and random effects models were used to assess the accumulation of evidence over time.

RESULTS

The five-year patient survival rate was significantly better in the DBD than in the DCD cohort. Non-significant differences were observed in 1-, 3- and 10-year patient survival and in the 1-, 3-, 5-, and 10-year graft survival rates between the two cohorts. The acute rejection rate was lower in the DCD cohort than in the DBD cohort. Extended criteria of donor status, delayed graft function and primary non-function were significantly higher in the DCD cohort than in the DBD cohort.

CONCLUSIONS

This study demonstrates that the short- and long-term survival graft and patient benefits are similar between DCD and DBD kidney transplants. Therefore, large, controlled DCD kidney programmes are urgently needed worldwide in order to increase the number of kidney transplants.

A comparison between robotic, laparoscopic and open hepatectomy: A systematic review and network meta-analysis

BACKGROUND

The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis.

METHODS

A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes.

RESULTS

The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort.

CONCLUSION

The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

Appraisal of the current guidelines for management of cholangiocarcinoma-using the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument

Cholangiocarcinoma (CC) is the second most common primary liver tumour. High-quality guidelines are essential for effective patient stratification and individualised treatment. This study aimed to appraise the methodological quality of existing guidelines for the resection of CC using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. A systematic search of the literature in Cochrane, PubMed, Google Scholar, and Embase was performed. Assessment of the clinical practice guidelines (CPGs) and consensuses was performed using the AGREE II instrument by four clinicians experienced in surgical practice and the AGREE II appraisal method. Literature searches identified 13 guidelines of highly variable quality according to the AGREE II criteria. The guidelines scored well in certain domains such as scope & purpose (median score across all guidelines; 65%), clarity of presentation (76%), and editorial independence (56%). However, they scored poorly for applicability (13%), rigour of development (30%), and stakeholder involvement (39%). None of the 13 guidelines was recommended universally for use without modification. Overall, the methodological quality of guidelines on the surgical management of CC is poor. Future updates should address and modify shortcomings detected by the AGREE II instrument, thereby facilitating better patient stratification and individualised treatment strategies.

Limberg flap versus Karydakis flap for treating pilonidal sinus disease: a systematic review and meta-analysis

Background

The Limberg flap reconstruction and the Karydakis flap reconstruction are the 2 most used off-midline closure techniques in pilonidal sinus surgery. The current evidence is inconclusive as to which is the optimal technique. The aim of this systematic review and meta-analysis was to compare differences in outcomes between these 2 flap-based techniques.

Methods

We identified studies by a systematic literature search of the Embase, MEDLINE (PubMed), Cochrane Library and Google Scholar databases and studies selected as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Only randomized controlled trials (RCTs) that compared the Limberg flap (standard or modified) and the Karydakis flap were included in this review.

Results

Operative time was shorter by 7 minutes in the Karydakis group than in the Limberg group (mean difference 7.00 min, 95% confidence interval [CI] 0.53 to 13.48). The seroma formation rate was significantly higher in the Karydakis cohort (odds ratio [OR] 0.36, 95% CI 0.24 to 0.56); however, after excluding studies with a high risk of bias, the sensitivity analysis showed no significant differences in seroma formation rate between the 2 techniques (OR 0.76, 95% CI 0.31 to 1.85). Other outcomes of interest showed no significant differences between the Limberg and Karydakis techniques.

Conclusion

There were no significant differences between the Limberg and Karydakis techniques. Future RCTs with strict adherence to CONSORT guidelines will further elucidate the efficacy of these surgical procedures.

Comparison of robotic vs laparoscopic vs open distal pancreatectomy. A systematic review and network meta-analysis

INTRODUCTION

The current evidence comparing oncological adequacy and effectiveness of robotic and laparoscopic distal pancreatectomy to open distal pancreatectomy for pancreatic adenocarcinoma is inconclusive. Recent pairwise meta-analyses demonstrated reduced blood loss and length of stay as the principal advantages of RDP and LDP compared to ODP. The aim of this study was to compare the three approaches to distal pancreatectomy conducting a pairwise meta-analysis and consequently network meta-analysis.

METHODS

A systematic literature search was performed using the databases, EMBASE, Pubmed, the Cochrane library, and Google Scholar. Meta-analyses were performed using both fixed-effect and random-effect models.

RESULTS

RDP cohort represented only 11% of the total sample; significantly younger patients with smaller size tumours were included in the RDP and LDP cohorts compared to ODP cohort. Significantly less blood loss and shorter length of stay were the advantages of both RDP and LDP compared to ODP. The ODP cohort included significantly more specimens with positive resection margins compared to RDP and LDP cohorts.

DISCUSSION

The results of the present study demonstrate that reduced blood losses and shorter length of stay are the advantages of RDP and LDP compared to ODP. However, demographic discrepancies, underpowered RDP sample and differences in oncological burden do not permit certain conclusions regarding the oncological safety of RDP and LDP for pancreatic adenocarcinoma.

Local anaesthetic infiltration via wound catheter versus epidural analgesia in open hepatectomy: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Although epidural analgesia (EA) provides effective pain control after open hepatectomy, postoperative hypotension is a common problem that limits ambulation. There is growing interest in alternative methods of pain control after open abdominal surgery, including a potential role for local anaesthetic infusion via wound catheter (WC). The aim of this study was to evaluate the available evidence for WC in open hepatectomy by conducting a meta-analysis of randomised trials.

METHODS

A systematic database search of literature published in the last 20 years was performed. Only randomised controlled trials (RCTs) were included in the study. Meta-analyses were performed using both fixed-effects and random-effects models.

RESULTS

WC patients had significantly faster functional recovery (WMD = -0.73 (-1.13, -0.32), I² = 0%, p = 0.004). There was no significant difference in pain scores on the first postoperative day (POD1). On POD2, WC patients had higher pain scores compared to EA patients (WMD = 0.29 (0.09, 0.49), I² = 0%, p < 0.004), but this corresponded with significantly lower opioid consumption in WC patients (WMD = -6.29 (-7.92, -4.65), I² = 62%, p < 0.001). There was no significant difference in major hepatectomy, incision length, complications, length of hospital stay or readmissions between groups.

CONCLUSION

Despite higher pain scores on the second postoperative day, functional recovery after open hepatectomy is faster in patients with wound catheters compared with epidural analgesia. Wound catheters should be considered the preferred mode of analgesia after open hepatectomy.

Gastrectomy Alone or in Combination With Hepatic Resection in the Management of Liver Metastases From Gastric Cancer: A Systematic Review Using an Updated and Cumulative Meta-Analysis

Background

Recent studies have demonstrated that hepatectomy in patients with synchronous hepatic gastric metastases may improve survival in certain patients. This study aimed to evaluate survival benefits of gastrectomy plus hepatectomy versus gastrectomy alone in patients with hepatic gastric metastases.

Methods

Studies were identified by a systematic search of Embase, PubMed, Cochrane Library, and Google Scholar databases. Traditional and cumulative meta-analyses were used to monitor the evidence over time.

Results

Eleven studies which included 861 patients compared gastrectomy plus hepatic resection in 349 patients with gastrectomy alone in 512 patients. Overall significantly better survival rates of 1, 2, 3, and 5 years were demonstrated for patients who underwent gastrectomy plus hepatic resection compared to patients who under underwent gastrectomy alone ((hazard ratio (HR) = 0.52 (0.39, 0.69), P < 0.001), (HR = 0.85 (0.74, 0.97), P = 0.01), (HR = 0.80 (0.72, 0.90), P = 0.003), (HR = 0.83 (0.78, 0.90), P < 0.001), respectively).

Conclusions

Carefully selected patients with hepatic gastric metastases may benefit from hepatic resection.

Simultaneous, Delayed and Liver-First Hepatic Resections for Synchronous Colorectal Liver Metastases: A Systematic Review and Network Meta-Analysis

Background

Systematic reviews and meta-analyses that compare simultaneous, delayed and liver-first approach for synchronous colorectal liver metastases have found no significant differences. The aim of this study was to determine the best treatment strategy on the basis of effect sizes and the probabilities of treatment ranking by using a network meta-analysis. Moreover, first-time pairwise and network meta-analyses were used to estimate the existing evidence, and their results were compared to detect any discrepancies between them.

Methods

Systematic review, pairwise meta-analysis and network meta-analysis were performed. The primary and secondary outcomes were 5-year overall survival and postoperative major morbidity, respectively.

Results

No significant differences in long-term survival and major morbidity were found amongst the three approaches. The hazard ratios (95% confidence interval) for 5-year overall survival for the simultaneous, delayed and liver-first approaches were 0.93 (0.69 - 1.24, P = 0.613), 0.97 (0.87 - 1.07, P = 0.596) and 0.90 (0.67 - 1.22, P = 0.499), respectively. Moreover, the liver-first approach with a surface under the cumulative ranking area score of 89% was ranked as the potentially best treatment option based on probabilities of treatment ranking.

Conclusions

On the basis of the relative ranking of treatments, the liver-first approach ranked first, followed by the delayed and simultaneous approaches. Therefore, a three-arm randomized controlled trial that compares the liver-first, simultaneous and delayed approaches needs to shed further light as to which is the best treatment option.

Split versus living-related adult liver transplantation: a systematic review and meta-analysis

BACKGROUND-OBJECTIVE

The outcomes of split liver transplantation between recipients of deceased donor split liver transplant (SLT) or live donor liver transplants (LDLT) have never been compared in meta-analysis. It is important to understand graft and recipient survival between recipients of these grafts.

METHODS

Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library and Google Scholar). Meta-analyses were performed using both fixed- and random-effects models. Patient survival and graft survival were obtained using the inverse variance hazard ratio method.

RESULTS

There were differences in the characteristics of the donors and recipients. Donors of the SLT were younger compared to LDLT cohort [mean difference (MD) = - 11.12 years (- 15.41 to - 6.84), p < 0.001] whilst recipients of LDLT were younger [MD = - 2.06 years (- 1.12 to - 3.01), p < 0.001]. Significantly fewer men received grafts after SLT, 45%, compared to those receiving LDLT, 55%, [OR = 0.66 (0.55 to 0.80), p < 0.001]. There were no significant differences detected in postoperative complications, graft and patient 1-, 3- and 5-year survival between the SLT and LDLT cohorts.

CONCLUSIONS

There is no apparent difference in overall survival, graft survival or complications between recipients of SLT or LDLT. However, characteristics of the donor and recipients differed suggesting the need for adequate risk-adjusted assessment of outcomes.

Hyperbilirubinemia as a Predictor of Appendiceal Perforation: A Systematic Review and Diagnostic Test Meta-Analysis

Background

Misdiagnosis of the severity of acute appendicitis may lead to perforation and can consequently result in increased morbidity and mortality. In this study, the role of hyperbilirubinemia as a predictor of perforation is assessed by performing a meta-analysis of diagnostic accuracy.

Methods

A systematic search of the literature published over the past 20 years was performed using the EMBASE, PubMed, Cochrane library, and Google Scholar databases.

Results

Low values of sensitivity, specificity, and diagnostic odds ratio (DOR) were detected: 0.21 (95% confidence interval (CI): 0.13 - 0.30, standard error (SE) = 0.43), 0.27 (95% CI: 0.15 - 0.43, SE = 0.73), and 0.10 (95% CI: 0.3 - 0.28, SE = 0.05), respectively. The positive likelihood ratio (PLR) was low (0.29 (95% CI: 0.27 - 0.91, SE = 0.76)), whereas the negative likelihood ratio (NLR) was high (2.88 (95% CI: 1.66 - 5.14, SE = 0.10)). The hierarchical summary receiver operating characteristic curve was positioned towards the lower right corner, and the area under the curve was 0.19, both indicating a low level of overall accuracy and discrimination. Compared with the PLR, the negative inverse likelihood ratio (1/LR^-) indicated that a positive result has a greater impact on the odds of disease than does a negative result.

Conclusions

Hyperbilirubinemia alone is not a reliable tool to predict perforation. Future studies should investigate whether the combined predictive values of bilirubin, C-reactive protein (CRP), and white blood cells are a more effective diagnostic tool.

To Use or Not to Use Opioid Analgesia for Acute Abdominal Pain Before Definitive Surgical Diagnosis? A Systematic Review and Network Meta-Analysis

Background

Despite the existing evidence, many physicians are reluctant to use opioid analgesia for acute abdominal pain.

Methods

We performed updated conventional and network meta-analyses. For the first time to our knowledge, direct and indirect evidence of any type of opioid analgesia was estimated and compared using network meta-analysis.

Results

There was no significant difference in the intensity of pain between the two cohorts (mean difference (MD) = 0.43 (-0.05 to 0.91), P = 0.08). In addition, no significant difference was detected in the rate of incorrect diagnoses between the opioid analgesia and the placebo cohorts (odds ratio (OR) = 0.79 (0.54 to 1.17), P = 0.24). Network meta-analysis demonstrated that the results of direct evidence of head-to-head comparisons of opioid analgesics with placebo were in accordance with the results of conventional meta-analysis. Moreover, estimation and comparison of the indirect evidence on the four opioid analgesics did not demonstrate significant differences in effect size.

Conclusions

Any type of opioid analgesic can be used safely for acute abdominal pain without risk of impairment of diagnostic accuracy.

Acute Appendicectomy or Conservative Treatment for Complicated Appendicitis (Phlegmon or Abscess)? A Systematic Review by Updated Traditional and Cumulative Meta-Analysis

Background

The existing evidence on the treatment of complicated appendicitis favors conservative treatment rather than acute appendicectomy. Update traditional meta-analysis and consequently cumulative meta-analysis was performed to track the accumulation of evidence over time.

Methods

Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library and Google Scholar databases. The main outcome measures were duration of the first hospitalization, overall duration of hospitalization, duration of intravenous (IV) antibiotic treatment, overall complications, abdominal/pelvic abscesses, wound infections, re-admissions and unplanned re-operations.

Results

Overall complications, abdominal/pelvic abscesses, wound infections and unplanned procedures were significantly lower in the conservative treatment cohort. In contrast, subgroup analysis of three randomized controlled trials (RCTs) revealed no significant difference in abdominal/pelvic abscesses (odds ratio (OR): 0.46, 95% confidence interval (CI): 0.17 - 1.29, P = 0.14). No significant differences were found in the duration of the first and overall hospitalizations. Of the note, high-quality RCTs demonstrated a shorter hospital stay by 1 day for the laparoscopic appendicectomy cohort compared to conservative treatment (mean difference (MD): -0.99, 95% CI: -1.31 to -0.67, P < 0.0001).

Conclusion

The present meta-analysis demonstrates that a shift in paradigm has begun, with a more widespread use of the laparoscopic approach for the management of complicated appendicitis.

Right lobe split liver graft versus whole liver transplantation: A systematic review by updated traditional and cumulative meta-analysis

INTRODUCTION

Advancements in surgical techniques and experience of donor-recipient pairing has led to a wider use of right split liver grafts in adults. An update meta-analysis was conducted to compare right split liver graft (RSLG) and whole liver transplantation (WLT) using traditional and cumulative approaches.

METHODS

Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library, and Google Scholar). Meta-analyses were performed using both fixed and random effects models. Patient and graft survival were obtained using the inverse variance hazard ratio method.

RESULTS

Donors were significantly younger in the RSLG group than in the WLT group (MD = -12.06 [-16.29 to -7.83]; P < .001). In addition, the model for end-stage liver disease (MELD) score was significantly lower in the RSLG group than in the WLT group (MD = -2.45 [-4.61 to -.28]; P = .03). However, cold ischaemia time was significantly longer by 1 h in the RSLG group than in the WLT group (MD = 57 [20.63-92.73]; P = .002). Overall biliary, vascular, and outflow tract complications and hepatic artery thrombosis were significantly lower in the WLT group than in the RSLG group (odds ratio [OR] = 1.75 [1.35-2.27], P < .001; OR = 1.91 [1.37-2.65], P = .006; Peto OR = 1.83 [1.19-2.82], P = .006; and Peto OR = 2.07 [1.39-3.10], P = .004, respectively). However, no difference in patient and graft survival was noted between the two cohorts.

CONCLUSIONS

Although the RSLG group had a higher postoperative complication rate than the WLT group, equal patient and graft survival benefits were observed.

Laparoscopic Versus Open Transverse Colectomy: A Systematic Review and Meta-Analysis

OBJECTIVES

The survival benefits, oncological adequacy, effectiveness, and safety of laparoscopic transverse colectomy (LTC) were compared with that of open transverse colectomy (OTC) using a meta-analysis.

METHODS

EMBASE, Medline, Cochrane library, and Google scholar databases were searched for the last 20 years. Meta-analyses were performed using both fixed-effects and random-effects models. Five-year disease-free survival and overall survival were estimated using the inverse variance hazard ratio method.

RESULTS

No survival benefits were detected between the two LTC and OTC cohorts. OTC showed shorter operative time by 38 min compared to LTC [mean difference (MD) = 38(15.23-60.77), p = 0.001]. However, LTC was associated with earlier postoperative recovery. The time to flatus and time to oral intake for LTC were MD = -1.12(-1.68 to -0.55, p = 0.001) and MD = -1.57(-2.38 to -0.76, p = 0.001), respectively. In addition, LTC was associated with a shorter hospital stay by 4.5 days [MD = -4.64(-7.52 to -1.75), p = 0.002].

CONCLUSIONS

Compared to OTC, LTC provides similar survival benefits, earlier postoperative recovery, and shorter hospital stay by 4.5 days.

Loop transverse colostomy versus loop ileostomy for defunctioning of colorectal anastomosis: a systematic review, updated conventional meta-analysis, and cumulative meta-analysis

Defunctioning of colorectal anastomosis either with loop transverse colostomy or ileostomy was evaluated using updated and cumulative meta-analyses. Studies were identified by a systematic search of Embase, PubMed, Cochrane Library, and Google Scholar databases and were selected as per the PRISMA checklist. Both randomised control trials (RCTs) and retrospective studies were included. A sensitivity analysis was performed, and a cumulative meta-analysis was performed to monitor evidence over time. Significantly more male patients underwent loop ileostomy than transverse colostomy [odds ratio (OR) = 0.59 (95% confidence interval (CI) 0.39, 0.90), p < 0.001, I² = 48%]. Significantly more colostomies were complicated by stoma prolapse than by ileostomies [OR = 6.32 (95% CI 2.78, 14.35), p < 0.001, I² = 0%). Patients with ileostomy demonstrated a significantly higher complication rate of high-output stoma than patients with colostomies [Peto OR = 0.16 (95% CI 0.04, 0.55), p = 0.004, I² = 0%]. Patients with colostomies demonstrated significantly more complications related to stoma reversal, such as wound infections and incisional hernias, than patients with ileostomies [OR = 3.45 (95% CI 2.00, 5.95), p < 0.001, I² = 0%; OR = 4.80 (95% CI 1.85, 12.44), p < 0.001, I² = 0%, respectively]. Overall complications related to stoma formation and closure did not demonstrate significant differences; however, their I² values were 82% and 76%, respectively, suggesting high heterogeneity, which may have influenced the results. A subgroup analysis of RCTs showed no discrepancies when compared to the whole sample. In the cumulative meta-analysis, the effect size of each study was non-significant for the entire period. The demonstrated significant differences did not translate in favour of ileostomy when the overall complications of stoma formation and reversal were evaluated. Confounding factors and underpowered samples may have influenced the results. Future multicentre RCTs with homogeneous populations and adequate power may demonstrate more conclusive evidence regarding the superiority of one procedure over the other.

Network Meta-Analysis of Adjuvant Chemotherapy following Resection of Colorectal Liver Metastases

Objective

Six principal adjuvant chemotherapy treatments (ACTs) are currently available for patients with resected colorectal liver metastases. This meta-analysis was designed to determine the optimal ACT, as evaluated by 2-year disease-free survival (DFS) and 5-year overall survival (OS) rates as well as by hepatic recurrences and adverse events (AEs).

Methods

A systematic literature search of the PubMed, EMBASE, Medline, Cochrane Library, and Google Scholar databases was performed. The probability of the optimal therapeutic scheme and the mean ranking were estimated for each treatment using network meta-analysis.

Results

Systemic chemotherapy (SCT) had the best 2-year DFS rate (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.48-1.27, 95% prediction interval [PI] = 0.17-3.56, surface under the cumulative ranking area [SUCRA] = 73) and the lowest AE rate (estimated SUCRA = 65 and predicted SUCRA = 62). Hepatic arterial infusion (HAI) plus SCT had the best 5-year OS rate (HR = 0.81, 95% CI = 0.64-1.01, 95% PI = 0.50-1.29) and the lowest hepatic recurrence rate (odds ratio = 2.87, 95% CI = 1.56-5.30, 95% PI = 0.61-13.62).

Conclusion

Both SCT and HAI plus SCT showed superior efficacy and safety. Clinical trials in homogeneous populations with strict selection criteria are needed to compare these two ACTs.

Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis

OBJECTIVE

This was a systematic review and meta-analysis to compare outcomes between patients undergoing simultaneous or delayed hepatectomy for synchronous colorectal liver metastases.

BACKGROUND

The optimal strategy for treating liver disease among patients with resectable synchronous colorectal liver metastases (CRLM) is unclear. Simultaneous resection of primary tumour and liver metastases may improve patient experience by reducing the number of interventions. However, there are concerns of increased morbidity compared to delayed resections.

METHODS

A systematic literature search was performed using EMBASE, Medline, Cochrane library and Google scholar databases. Meta-analyses were performed using both random-effects and fixed-effect models. Publication and patient selection bias were assessed with funnel plots and sensitivity analysis.

RESULTS

Thirty studies including 5300 patients were identified. There were no statistically significant differences in parameters relating to safety and efficacy between the simultaneous and delayed hepatectomy cohorts. Patients undergoing delayed surgery were more likely to have bilobar disease or undergo major hepatectomy. The average length of hospital stay was six days shorter with simultaneous approach [MD = -6.27 (95% CI: -8.20, -4.34), p < 0.001]. Long term survival was similar for the two approaches [HR = 0.97 (95%CI: 0.88, 1.08), p = 0.601].

CONCLUSION

In selected patients, simultaneous resection of liver metastases with colorectal resection is associated with shorter hospital stay compared to delayed resections, without adversely affecting perioperative morbidity or long-term survival.

Extramammary Paget's disease of the vulva

Vulvar Paget's disease is an extremely rare neoplasm that accounts for less than 1% of the vulvar malignancies. We present a case of a 75-year-old woman, who had an eczematoid lesion involving the labia majora and minora bilaterally, with infiltration to the clitoris. Enlarged non-fixed lymph nodes were palpable in the inguinal region bilaterally. A biopsy of the vulva showed Paget's disease. She underwent radical vulvectomy with bilateral inguinal lymph node dissection. The patient remained disease free at 6-month follow-up.

Primary ileocaecal B-cell non-Hodgkin lymphoma (NHL): a rare underlying cause of right iliac fossa pain

Primary gastrointestinal non-Hodgkin lymphomas (NHL) account for about 0.9% of all gastrointestinal tract tumours. They are usually associated with ulcerative colitis, Crohn's disease, previous radiotherapy, renal transplantation and AIDS. We present a 36-year-old immunocompetent man, previously well with abdominal pain, weight loss and palpable mass in the right iliac fossa. A CT scan of the abdomen showed a thickening of the terminal ileum and the caecum with characteristic aneurysmal luminal dilation. Given the patient's presentation and radiology findings, a right hemicolectomy was performed. The suspected diagnosis of NHL, which was based on the imaging findings, was confirmed at histological analysis.

Pigmented epithelioid melanocytoma: a new concept encompassing animal-type melanoma and epithelioid blue nevus

Pigmented epithelioid melanocytoma (PEM) is a recently proposed term which encompasses those melanocytic tumours previously designated as 'animal-type melanoma' or 'pigment-synthesising melanoma' and 'epithelioid blue nevus', the latter known to be associated with Carney's complex. We report a case of PEM in a previously well 26-year-old Caucasian woman who presented with a dark pigmented nodule on the anterior chest wall.

Granular cell breast tumour mimicking infiltrating carcinoma

Granular cell tumour (GCT) is a rare, usually benign neoplasm that can mimic carcinoma on breast imaging. GCT can originate anywhere in the body but is most frequently found in the head and neck region, particularly in the tongue. Of the reported cases, 6% have occurred in the breast, most commonly in the upper inner quadrant. We report a case of GCT of the breast presenting as a spiculated mass infiltrating the greater thoracic muscle on breast screening mammogram.

Extraocular sebaceous carcinoma mimicking benign sebaceous cyst

Extraocular sebaceous carcinoma (SC) is an exceptionally rare neoplasm and has been confused in the past with basal cell carcinoma showing sebaceous differentiation. However, in contrast to the latter tumour, SC can be an aggressive cancer. We describe the case of a 55-year-old man with a 3-year history of a 5 × 2 cm lesion on the posterior thoracic wall. It had increased in size during this period but was otherwise asymptomatic. There was no significant past medical history or lymphadenopathy. Nor was there a family history of malignancy. The lesion was totally excised. The histopathological report revealed SC. As this neoplasm may be associated with Muir-Torre syndrome, the patient was screened for underlying internal neoplasia. All haematological, biochemical and tumour markers, imaging and endoscopic examinations were normal. Since SC may appear before the development of internal malignancy, our patient was scheduled for follow-up visits every 3 months.