Association of cirrhosis severity with outcomes after hip fracture repairs: A propensity-score matched analysis using a large inpatient database

BACKGROUND

Advanced cirrhosis is associated with increased mortality in certain surgeries, but the impact of cirrhosis severity on outcomes in patients with hip fractures remains unclear.

METHODS

In a large nationwide administrative database of hospitalized patients, we compared postoperative outcomes in patients with hip fractures across different Child-Pugh classes of cirrhosis in Japan. Using the Japanese Diagnosis Procedure Combination Database, we identified 833,648 eligible patients diagnosed with hip fractures and underwent surgery between July 2010 and March 2021. Three sets of 1:1 propensity-score matching were performed for four groups: non-cirrhosis cases and Child-Pugh classes A, B, and C. We compared in-hospital mortality, length of stay, hospitalization fees, readmission, and complications in non-cirrhosis cases vs. Child-Pugh class A, Child-Pugh class A vs. B, and Child-Pugh class B vs. C.

RESULTS

Propensity-score matching created 1065 pairs for non-cirrhosis vs. Child-Pugh class A, 1012 for Child-Pugh class A vs. B, and 489 for Child-Pugh class B vs. C. In-hospital mortality did not differ between non-cirrhosis cases and those with Child-Pugh class A. However, in-hospital mortality was significantly higher in patients with Child-Pugh class B than in those with class A (1.5 % vs. 5.9 %; RD 4.45 %; 95 % CI: 2.79%-6.10 %), and higher in patients with Child-Pugh class C compared with class B (6.3 % vs. 28.4 %; RD 22.09 %; 95 % CI: 17.54%-26.63 %). Patients in more severe Child-Pugh classes had longer hospital stays, higher hospitalization fees, and higher complication rates.

CONCLUSION

Patients with hip fractures and cirrhosis who are at high risk of poor postoperative outcomes could be identified. This study highlights the significantly higher in-hospital mortality observed in patients with Child-Pugh class C cirrhosis undergoing hip fracture surgery compared to those with class B. These findings underscore the need for careful risk-benefit discussions, considering the severity of cirrhosis, surgical risks, and care goals for each patient.

Short-term outcomes in mesh versus suture-only treatment of burst abdomen: a case-series from a university hospital

PURPOSE

Surgery for a burst abdomen after midline laparotomy is associated with later incisional hernia formation. Accommodating prophylactic measures, notably mesh augmentation, are of interest. However, data regarding safety and outcomes are scarce. This study aimed to evaluate the short-term risk profile of mesh prophylaxis in the context of a burst abdomen.

METHODS

This is a single-center prospective study of patients suffering from burst abdomen from 2021 to 2023. A treatment protocol for the management of burst abdomen was introduced, including the synthetic, partially absorbable onlay mesh. Adult patients (≥ 18 years) with a life expectancy of > 1 year with no plans of future pregnancies were recommended to be treated with a prophylactic mesh. In this analysis, adult patients were included if they suffered from a burst abdomen after elective or emergency laparotomy. The study evaluates short-term outcomes, including 90-day wound complications, length of stay, and mortality.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria and underwent treatment for a burst abdomen during the study period. Thirty-eight patients were treated with a suture-only technique, and 29 patients were supplemented with a mesh. 13 of 14 observed wound complications in the mesh group were of mild degree (Clavien Dindo 1-3b), while one patient (3%) needed mesh-explantation. The 90-day mortality rate was 21% and comparable between suture-only and mesh techniques.

CONCLUSION

Mesh augmentation in surgery for a burst abdomen seems safe in well-selected patients at 90 days follow-up. Long-term data on the prophylactic effect on hernia development is needed.

The 12-Year Experience of the Hungarian Pancreatic Study Group

The Hungarian Pancreatic Study Group (HPSG) was established with the aim of advancing pancreatology. Our summary outlines the methodologies, key results, and future directions of the HPSG. Methodological elements included, the formation of strategic national and international collaborations, the establishment of patient registries and biobanks, and a strong focus on education and guideline development. Key results encompassed, pioneering research on pancreatic ductal function and the role of cystic fibrosis transmembrane conductance regulator (CFTR) in inflammation, significant advancements in understanding acute and chronic pancreatitis, and the execution of numerous clinical trials to explore new therapeutic approaches. Despite challenges, such as securing funding and translating research into clinical practice, the HPSG's commitment to patient care and scientific innovation has been unwavering. The group aims to deepen research into pancreatic cancer and chronic pancreatitis, conduct more randomized controlled trials (RCTs), and expand its efforts internationally by involving global staff and patients. The authors hope that this summary inspires others to undertake similar initiatives and contribute to the global advancement of medical research and patient care in pancreatology.

Systematic review and meta-analysis on robotic assisted ventral hernia repair: the ROVER review

INTRODUCTION

Robotic surgery for ventral hernia repair (VHR) is gaining attention for its potential advantages over laparoscopic and open techniques. This approach combines the advantages of minimally invasive surgery with the ability to perform technically challenging procedures, often required in open surgery but difficult with conventional laparoscopy. We aim to evaluate the efficacy and safety of robotic VHR compared to other surgical approaches, focusing on postoperative complications, operative time, and costs.

MATERIAL AND METHODS

A systematic review with meta-analysis were conducted, including 67 studies from January 2010 to May 2023 on Robotic VHR compared with other techniques. Primary outcome was 30-days postoperative complications; SSI, SSO, seroma, mortality, recurrence, length of hospital stay, operative time and costs were analysed as secondary outcomes.

RESULTS

Robotic surgery was associated with longer operative times compared to both laparoscopic (MD 64.67 min; p < 0.001) and open repairs (MD 69.69 min; p < 0.001). However, it resulted, compared to open surgery, in fewer SSIs (OR 0.62; p 0.05), mortality (OR 0.44; p 0.04) and shorter hospital stay (MD -3.77 days; p < 0.001). No differences were found in overall complications or length of stay between robotic and laparoscopic approaches but higher costs and longer operative times were reported in robotic VHR.

CONCLUSIONS

Based on the currently available low-quality evidence, robotic VHR appears to offer limited advantages compared to laparoscopic techniques. However, when compared to open approaches, robotic VHR may demonstrate reduced postoperative complications and shorter hospital stays even if an higher rate of seroma formation was retrieved probably related to technical details. Nevertheless, longer operative times and higher costs remain significant limitations. Further high-quality comparative studies are warranted to assess long-term outcomes and cost-effectiveness.

Trends and cross-country inequalities in the global burden of inguinal, femoral, and abdominal hernia from 1990 to 2021, with projections from 2022 to 2035: a cross-sectional study

BACKGROUND

The global burden of inguinal, femoral, and abdominal hernias remains significant, particularly in low- and middle-income countries, despite medical advancements. This study aims to examine trends and cross-country inequalities in the burden of these hernias from 1990 to 2021 and project future trends to 2035.

METHODS

Utilizing Global Burden of Diseases (GBD) 2021 data, we analyzed prevalence, incidence, mortality, and disability-adjusted life years (DALYs) across 204 countries and territories. Development levels were quantified using the sociodemographic index (SDI). Analyses included descriptive statistics, joinpoint regression, Spearman correlation, frontier analysis, and a Bayesian age-period-cohort model for forecasting.

RESULTS

From 1990 to 2021, global prevalence increased from 13.7 million to 16.4 million, while the age-standardized rate (ASR) decreased by 24.74%. Incident cases rose from 5.8 million to 7.2 million, with a 16% decline in ASR. Deaths increased from 42,118 to 48,012, but ASR fell by 45.16%. DALYs decreased from 2.6 million to 2.3 million, with a 42.31% drop in ASR. Projections to 2035 indicate continued growth in cases, with varying ASR trends. Inequality analyses revealed persistent disparities, disproportionately affecting populations with higher socioeconomic development.

CONCLUSIONS

Significant disparities persist in the global burden of hernias, with increasing cases despite declining ASRs. Continued growth and inequalities underscore the need for targeted interventions and policies.

Clinical importance of incisional hernia in patients resected for colorectal liver metastases: quality of life and abdominal wall symptoms

PURPOSE

Incisional hernia (IH) after open liver surgery is a well-recognized complication. The clinical importance of IH detected on computed tomography in terms of objective abdominal wall discomfort and impairment of quality of life (QoL) is less well known.

METHODS

Patients who underwent curative surgery for colorectal liver metastases between 2010 and 2015 at a single center and were alive in February 2017 were asked to complete a ventral hernia pain questionnaire and the EORTC QLQ-C30 QoL questionnaire.

RESULTS

A total of 105 patients (80%) completed the questionnaires. Forty-three patients (42%) developed IH. The majority (77%) of IHs were < 2.5 cm. Patients who had an IH before liver surgery developed a new IH to a greater extent (P = 0.001). There were no significant differences regarding abdominal wall symptoms and QoL between patients with and without IH. However, about half (48%) of all patients had abdominal wall symptoms after a median follow-up of 34 months.

CONCLUSION

Radiologically detected IH after open liver surgery has low clinical importance. About half of all patients who underwent liver surgery experienced abdominal wall symptoms a long after surgery, but these symptoms were not related to IH.

Discrepancies between physician-assessed and patient-reported complications after cystectomy - a prospective analysis

PURPOSE

Despite the high incidence of perioperative complications following cystectomy, there is a lack of evidence regarding patients' perceptions. Moreover, discrepancies between established complication grading systems and the patient's perspective remain unexplored.

METHODS

We prospectively evaluated perioperative complications after cystectomy using the Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI). The CDC and CCI were compared to patient-reported complication grades through Spearman correlation analysis. Discrepancies between physician-assessed and patient-reported complication grades were then evaluated. The study was registered at ClinicalTrials.gov (NCT05153694).

RESULTS

Between December 2021 and March 2024, 172 patients underwent open cystectomy at our department. Of those, 154 provided written consent to participate in the study, and 111 completed the post-discharge questionnaire. We found a moderate correlation between physician-assessed and patient-reported complication grades (CDC: r = 0.34, CCI: r = 0.39; p < 0.001). Patients with matching grades were defined as realists (50%). Those who reported lower complication grades than assessed by physicians were defined as optimists (38%), while those who reported higher grades were defined as pessimists (12%). Optimists rated the preoperative medical information better than pessimists ("very good": 79% vs. 38%, p = 0.006). We found no significant differences between optimists and pessimists regarding age, gender, tumor characteristics or educational level.

CONCLUSION

In our prospective study, the correlation between physician-assessed and patient-reported complication grades was only moderate. Only half of the cystectomy patients accurately perceived the severity of their complications. Our findings represent the first study to investigate patients' perspectives on complications in urology and underscore the importance of thorough preoperative medical information.

Selective epithelial expression of KRASG12D in the Oncopig pancreas drives ductal proliferation and desmoplasia that is accompanied by an immune response

Pancreatic ductal adenocarcinoma (PDAC) remains a formidable challenge in oncology, characterized by a high mortality rate, largely attributable to delayed diagnosis and the intricacies of its tumor microenvironment. Innovations in modeling pancreatic epithelial transformation provide valuable insights into the pathogenesis and potential therapeutic strategies for PDAC. We employed a porcine (Oncopig) model, utilizing the Ad-K8-Cre adenoviral vector, to investigate the effects of variable doses (107 to 1010 pfu) on pancreatic epithelial cells. This vector, the expression from which being driven by a Keratin-8 promoter, will deliver Cre-recombinase specifically to epithelial cells. Intraductal pancreatic injections in transgenic Oncopigs (LSL-KRASG12D-TP53R167H) were performed with histologically based evaluation at 2 months post-injection. Specificity of the adenoviral vector was validated through Keratin-8 expression and Cre-recombinase activity. We confirmed that the Ad-K8-Cre adenoviral vector predominantly targets ductal epithelial cells lining both large and small pancreatic ducts, as evidenced by Keratin 8 and CAM5.2 staining. Higher doses resulted in significant tissue morphology changes, including atrophy, and enlarged lymph nodes. Microscopic examination revealed concentration-dependent proliferation of the ductal epithelium, cellular atypia, metaplasia, and stromal alterations. Transgene expression was confirmed with immunohistochemistry. Desmoplastic responses were evident through vimentin, α-SMA, and Masson's trichrome staining, indicating progressive collagen deposition, particularly at the higher vector doses. Our study suggests a distinct dose-response relationship of Ad-K8-Cre in inducing pancreatic epithelial proliferation and possible neoplasia in an Oncopig model. All doses of the vector induced epithelial proliferation; the higher doses also produced stromal alterations, metaplasia, and possible neoplastic transformation. These findings highlight the potential for site-specific activation of oncogenes in large animal models of epithelial tumors, with the ability to induce stromal alterations reminiscent of human PDAC.

Penetrating versus non-penetrating mesh fixation in laparoscopic groin hernia repair

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of penetrating versus non-penetrating mesh fixation in adults receiving laparoscopic groin hernia repair.

ASA score is an independent predictor of 1-year outcome after moderate-to-severe traumatic brain injury

PURPOSE

This study aimed to investigate whether incorporating pre-injury health status, measured by the American Society of Anesthesiologists (ASA) score, improves outcome prediction models for moderate-to-severe traumatic brain injury (msTBI) patients.

METHODS

We conducted a retrospective single-center study of msTBI patients (2005-2021). The primary outcome was 1-year Glasgow Outcome Scale (GOS, dichotomized as GOS1-3 (unfavorable) vs. 4-5 (favorable)), and secondary outcome was 90-day mortality. Logistic regression evaluated the contribution of ASA score to the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) core + CT outcome prediction model incorporating age, admission GCS, pupillary reactivity, Marshall CT classification, hypoxia, hypotension, epidural hematoma, and subarachnoid hemorrhage.

RESULTS

Among the 720 adult patients that were included 51% had an unfavorable GOS at 1 year. The 90-day mortality was 19%. ASA score and TRISS were independently associated with both outcomes (p < 0.001). Incorporating the ASA score to our IMPACT model significantly enhanced its explanatory value of dichotomized GOS (35% vs. 32% variance explained, p < 0.001) and improved the model's prognostic accuracy.

CONCLUSION

In this retrospective single-center cohort study, we found that ASA score improves existing prognostic models for msTBI. Incorporating this simple comorbidity measure could enhance outcome prediction and support more personalized acute management. Future prospective studies are needed to validate these results.

Effect of Low-Dose Ketamine Infusion in the Intensive Care Unit on Postoperative Opioid Consumption and Traumatic Memories After Hospital Discharge: A Randomized Controlled Trial

BACKGROUND

Low-dose ketamine may have an opioid-sparing effect in critically ill patients but may also predispose them to traumatic memories. We evaluated the effects of low-dose ketamine infusion in the intensive care unit (ICU) on fentanyl consumption and traumatic memories after hospital discharge.

METHODS

This randomized, double-blind, controlled trial was conducted at a university-based surgical ICU. 118 adult patients who were admitted to the ICU after noncardiac, nonneuro, nontrauma surgery between March 2019 and May 2021 were randomized to receive ketamine 1.5 µg/kg/min (n = 60) or placebo (n = 58). Fentanyl was given to achieve pain control (10-point numerical rating scale pain score [NRS] < 4) and sedation control (Richmond Agitation and Sedation Scale [RASS] level between -2 and 0). A secondary study was conducted by a telephone interview after ICU discharge using the Thai version of the posttraumatic stress disorder (PTSD) questionnaire to evaluate signs and symptoms of PTSD and traumatic memories to the time spent in the ICU.

RESULTS

24-hour fentanyl consumption was lower in patients who received ketamine compared with placebo (399 µg [95% confidence interval {CI}, 345-454] vs 468 µg [95% CI, 412-523], difference -68 µg; 95% CI, -67 to -69; P = .041); RASS and NRS scores did not differ between the 2 groups. Exploratory effect modification analysis suggested that the opioid-sparing effect of ketamine may be more relevant in patients with intraabdominal surgery (P-for-interaction = 0.012, difference, -177 µg; 95% CI, -204 to -149 µg; P = .001). No acute adverse effects of ketamine were observed. The secondary study included the information from 91 patients from the primary study. Long-term follow-up data was available for 45 patients (23 in the control group, 22 in the ketamine group), and the evaluations were taken 43 ± 8 months after ICU discharge. In this secondary study, ketamine use was associated with a higher incidence of frightening and delusional memories of critical illness and ICU treatment (65% vs 41%, P = .035).

CONCLUSIONS

Low-dose ketamine is associated with a small but statistically significant reduction (15%) of postoperative opioid consumption in the ICU. Our secondary study revealed that patients who received low-dose ketamine during fentanyl-based postoperative pain therapy in the ICU recalled more frightening and delusional memories after ICU discharge.

Impact of Minimal Incision Repair of Rectus Abdominis Diastasis on Quality of Life and Stress Incontinence: A Prospective Study

Aim

This study evaluates the impact of the minimal incision repair of rectus abdominis diastasis (MIRRAD) procedure on physical activity, muscle strength, quality of life, and overall satisfaction in women with postpartum rectus abdominis diastasis (PP-RAD).

Methods

A cohort of 31 female patients, aged 20-50 years, diagnosed with PP-RAD unresponsive to conservative treatment, underwent the MIRRAD procedure. Assessments were conducted preoperatively and 1 year postoperatively, these included the Modified Abdominal Trunk Function Protocol (MATFP), Disability Rating Index (DRI), and Urinary Disability Index (UDI) questionnaires. Physical activity intensity was monitored using accelerometers.

Results

Significant improvements were observed in vigorous physical activities (Z = -2.352, p = 0.019), vector magnitude counts per minute (Z = -2.163, p = 0.031), and steps per minute (Z = -3.131, p = 0.002). DRI showed significant improvements in physical tasks like dressing, walking, and strenuous work (Z ranging from -2.705 to -4.603, p < 0.001). UDI indicated significant improvements in urinary symptoms, including reduced frequency (Z = -2.984, p = 0.003) and less urinary leakage (Z = -2.357, p = 0.018). MATFP demonstrated gains in back and abdominal muscle strength (Z = -4.321, p < 0.001) and trunk stability (Z = -3.991, p < 0.001).

Conclusion

The MIRRAD procedure significantly improves physical strength, trunk stability, and urinary function, enhancing daily activities and overall physical health in women with PP-RAD. Further research is recommended to evaluate long-term outcomes.

A Systematic Review of Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Management of Inguinal Hernias in the 21st Century

Background: In the 21st century, the management of groin hernias (GHs) has evolved from watchful waiting (WW) to robotic hernia repair (RHR). The present study interrogates the status of robotics in the context of current repairs and provides one author's perspectives. Methods: A systematic review was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for studies comparing open (OHR) to robotic hernia repair (RHR); RHR to laparoscopic hernia repair (LHR); or OHR vs. LHR vs. RHR. The historical context was extracted from previous reviews. Results: Fifty-four studies were included in the analysis. Three techniques have withstood the test of time: OHR (tissue and mesh repairs), laparo-endoscopic (TEP and TAPP), and RHR. The literature indicates that RHR is safe and effective for the management of groin hernias. Operative times and costs remain a concern when using this technique. While the number of overall complications with RHR is similar to OHR, in a minority of cases, complications are more consequential with the robotic platform. Conclusions: RHR has emerged as an unequivocally powerful technique for the management of GHs. OHR remains the technique of choice for local/regional anesthesia, posterior recurrences, and in centers that lack other platforms. In low- and middle-income countries, OHR is the most utilized technique. Centers of excellence should offer all techniques of repair including WW.

Evaluation of Rectus Abdominis Muscle Using High-Frequency Ultrasound and Shear Wave Elastography to Construct a Risk Prediction Model for Postpartum Low Back Pain

RATIONALE AND OBJECTIVES

This study aimed to develop a risk prediction model for low back pain (LBP) using high-frequency ultrasound to measure rectus abdominis muscle activity in postpartum women.

MATERIALS AND METHODS

This study included 197 pregnant women who delivered at our hospital and underwent routine postpartum follow-up. High-frequency ultrasound was used to assess the inter-rectus distance, thickness, and elasticity of the rectus abdominis muscle. Follow-up data were collected until six months after delivery, including information on LBP and exercise. Statistical analysis was performed to identify independent risk factors for postpartum LBP and build a risk prediction model.

RESULTS

Univariate and multivariate logistic regression analyses revealed that rectus abdominis thickness and exercise were significant independent factors associated with postpartum LBP. There was no significant correlation between rectus abdominis diastasis, body mass index (BMI), or LBP. The risk prediction model corresponding to the minimum AIC value (205.19) was Y= 8.16-1.13 ×thickness of the rectus abdominis-3.09 ×exercise. The ROC curve indicated that the optimal diagnostic cut-off value of the prediction model was 0.314, with an area under the curve (AUC) of 0.813. The sensitivity, specificity, positive and negative predictive values, and accuracy were 62.0%, 78.0%, 65.3%, 75.4%, and 71.6%, respectively.

CONCLUSION

A risk prediction model for postpartum LBP built using high-frequency ultrasound measurements of the rectus abdominis muscle may accurately predict postpartum LBP during the early postpartum period.

Recurrence of gallstones: a comprehensive multivariate analysis of clinical and biochemical risk factors in a large Chinese cohort of 16,763 patients

BACKGROUND

Gallstone disease is common, with a prevalence of 5%-22% in Western countries and 6.3%-12.1% in Chinese adults, increasing with age. Postsurgery recurrence is high and analyzing recurrence factors helps identify high-risk patients and preventive strategies. This study explores the differences in stone types and factors associated with postoperative recurrence.

METHOD

Data from 16,763 patients treated for gallstones at Shandong Third Hospital (2017-2023) were collected. Variables such as age, gender, stone type and size, comorbidities and biochemical results were analyzed using rank sum test, chi-square test, odds ratio (OR) and logistic regression.

RESULTS

Among 16,763 patients, females were slightly more numerous, with ages predominantly in the 60-74 range. Gallbladder stones were the most common type, with a low recurrence rate. Recurrence was significantly associated with stone size, venous thrombosis, respiratory diseases, and cirrhosis. Different stone types varied in terms of complications, gender, age, and recurrence.

CONCLUSIONS

Different stone types varied by comorbidities, gender, age, and recurrence, influencing recurrence risk. While the direct effect of stone type on recurrence is unclear, comorbidities play a crucial role. Larger, multicenter studies are needed to improve treatment guidance.

The risk of preterm delivery after appendectomy during pregnancy is higher in the face of a negative appendectomy

BACKGROUND

Reported outcomes after appendectomy during pregnancy remain inconclusive, and the risk for preterm delivery is not necessarily procedure-related.

METHODS

This retrospective cohort study included 185 pregnant women who underwent appendectomy during pregnancy and gave birth between 2005 and 2022, compared using a 3:1 ratio to 555 parturients who did not undergo surgery. clinical, obstetrical and neonatal outcomes were analyzed.

RESULTS

Laparoscopic appendectomy was the most common procedure (117/185; 63.2 ​%) whereas 68/185 (36.8 ​%) had open appendectomy. Pathological findings revealed that 141/185 cases (76.2 ​%) had an inflamed appendix, while 44/185 (23.8 ​%) were classified as having a "white appendix" (negative appendectomy). Preterm delivery occurred more frequently in the appendectomy group [22/185 (11.9 ​%) vs 30/555 (5.4 ​%), p ​= ​0.003] with even higher incidence in negative appendectomies compared to inflamed appendix cases [9/44 (20.5 ​%) vs 13/141 (9.2 ​%), p ​= ​0.044]. Multivariate analysis identified appendectomy (but not an inflamed appendix) as the sole significant risk factor for preterm birth (odds ratio 2.3, CI 1.26-4.15, p ​= ​0.006).

CONCLUSION

Preterm delivery correlates with negative appendectomies. Careful assessment is essential to avoid unnecessary surgical interventions during pregnancy.

Fluorescence-guided inguinal hernia repair with heightened nerve visualization to prevent chronic post-operative inguinal pain: Case report

INTRODUCTION

Iatrogenic injury to the ilioinguinal nerve and its branches during anterior inguinal hernia repair is a cause of chronic inguinal pain in up to 12 % of patients undergoing this operation. The risk of nerve injury is high, given the nerves' relatively small caliber and strictly-confined space through which they pass. In the current report, we describe using a novel fluorescence imaging system developed to detect nerve autofluorescence in a 66-year-old man who presented with a left-sided Type II inguinal hernia and underwent inguinal hernioplasty.

CASE PRESENTATION

Under general anesthesia, a left inguinal hernioplasty with mesh was performed using the Lichtenstein technique through an anterior approach. During surgery, a Dendrite® Imaging camera (Dendrite® Imaging, Germany) was employed to allow the surgical team to alternate freely between standard operating room (white) light and near-ultraviolet light (NUVL), specifically to enhance visualization of the ilioinguinal nerve and its branches. Under white light, neither the ilioinguinal nerve nor any of its branches were clearly visible. However, under NUVL, all fluoresced brightly and were easily avoided throughout the course of the hernia repair. The operation proceeded with no intraoperative or postoperative complications.

DISCUSSION

In this case, autofluorescence of the ilioinguinal nerve and its branches under NUVL utilizing a novel, hand-held fluorescent camera during hernia repair aided in their visualization and appeared to help prevent nerve injury.

CONCLUSION

New intraoperative technology that allows nerves to auto-fluoresce intra-operatively under NUVL warrants larger series and comparative trials to evaluate its efficacy at reducing iatrogenic nerve injury during inguinal hernioplasties.

Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

Gender changes in oral and maxillofacial surgery (OMFS) in the UK 1996 to 2030. Current trends suggest gender parity of those joining the OMFS specialist list may be achieved by 2048

In their 2022 paper Newman et al compared gender diversity between UK surgical specialties. It omitted the specialty of oral and maxillofacial surgery (OMFS), which is one of the ten General Medical Council recognised surgical specialties. When challenged, the authors did not provide data for OMFS. This paper analyses OMFS using a similar statistical approach but using specialty data rather than that held by NHS Digital. Data returned from NHS Digital about OMFS in 2022 did not accurately reflect known data. Alternative data was obtained from the General Medical Council with a Freedom of Information request for the OMFS specialist list in January 2024. These data were combined with a database of current OMFS trainees and retired OMFS consultants. For OMFS specialists, their date of entry onto the OMFS specialist list was used. For current trainees the average duration of OMFS training was added to the start date of their training. For both groups the gender cited on the GMC listing was used. The dataset consisted of 862 UK surgeons: 114 retired OMFS consultants, 571 currently on the OMFS specialist list and 177 in OMFS specialty training. Of this group 734 (85%) were male and 128 (15%) female. By plotting year of entry onto the OMFS specialist list for specialists and estimated year of Completion of Surgical Training for specialty trainees using linear projection in Excel©, gender parity of those joining the OMFS specialist list could happen in 2048 (24 years).

Comparison of the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with and without diabetes: a meta-analysis

BACKGROUND

Pancreatitis is a common complication for patients receiving endoscopic retrograde cholangiopancreatography (ERCP). The objective of the meta-analysis was to compare the incidence of post-ERCP pancreatitis (PEP) in individuals with and without pre-existing diabetes.

METHODS

A comprehensive review of the existing literature was carried out in PubMed, Embase, and Web of Science to identify applicable observational studies. The data were combined using a random-effects model while accounting for potential heterogeneity.

RESULTS

A total of 16 datasets from 14 observational studies involving 158,847 patients who received ERCP were included. Among them, 26,823 (16.9%) had pre-existing diabetes, and 24,654 (15.5%) had developed PEP. The pooled results showed that, compared to patients without diabetes, those with pre-existing diabetes had a lower incidence of PEP (odds ratio: 0.77, 95% confidence interval: 0.63 to 0.94, p = 0.01; I2 = 52%). A sensitivity analysis conducted by excluding one dataset at a time showed similar results (OR 0.74 to 0.81, p all < 0.05). Further subgroup and meta-regression analyses indicated that the link between diabetes and a decreased likelihood of PEP was not notably influenced by study factors such as country, average age, male representation, diabetes prevalence, incidence of PEP among the patients studied, diagnostic methods for PEP, or study quality scores.

CONCLUSIONS

Integrated evidence from observational studies currently indicate that diabetes could potentially act as a protective element against PEP. However, it is important to confirm these findings through extensive prospective studies that account for various influencing factors.

Emergency department trends for inguinal hernia and gallbladder disease before and after COVID-19 scheduled surgery interruptions: lessons for hospital capacity management

OBJECTIVES

Postponing scheduled surgeries may alleviate emergency department (ED) crowding by increasing inpatient beds for ED patients but the impact of such measures are unclear. We determined if scheduled surgery cancellations for inguinal hernia and gallbladder disease during the coronavirus pandemic affected ED presentations, hospitalizations, and complications.

METHODS

This database review included Albertans ≥ 18 with ED presentations for inguinal hernia and gallbladder disease from March 1, 2018 to May 31, 2022. The primary outcome examined ED hospitalizations and complications in the pre- (March 1, 2018-March 18, 2020) and post-cancellation (May 4, 2020-May 31, 2022) periods utilizing interrupted time series analysis. The secondary outcome reported scheduled surgery trends.

RESULTS

78,315 (10.6% inguinal hernia n = 8268; 89.4% gallbladder disease n = 70,064; n = 17 both inguinal hernia and gallbladder disease) patients were included. The post-cancellation period experienced a decreased trend change for inguinal hernia patients who received hospital admission (- 146.0%; p < 0.001), urgent interventions (- 171.0%; p < 0.001), and hernia repairs (- 164.0%; p < 0.001). For gallbladder disease patients, the post-cancellation period demonstrated a decreased trend in hospital admission (- 106.0%; p = 0.038) and an increased trend in day surgery transfers (- 1285.0%; p = 0.015) and median ED length of stay (82.0%; p = 0.0042). During the cancellation period, inguinal hernia and gallbladder disease surgeries decreased by 66.7% and 55.6%, respectively.

CONCLUSIONS

Despite a two-month surgery cancellation period, inguinal hernia and gallbladder disease patients demonstrated minimal differences in outcomes. During periods of ED boarding and crowding, scheduled surgery cancellations may be considered with minimal risk of potential adverse patient effects.

Risks and use of ERCP during the diagnostic workup in a national cohort of biliary cancer

BACKGROUND

In biliary cancer, the indication of endoscopic intervention might be diagnostic as well as therapeutic, in the latter situation with the aim to relieve biliary obstruction e.g. by stenting. Our aim was to investigate the use of endoscopic biliary interventions during the diagnostic workup of biliary cancers in a national cohort, and to evaluate their complications, especially cholangitis and pancreatitis.

METHODS

This is a registry-based study of national cohort of patients with biliary cancers in Sweden 2010-2020. The use of endoscopic retrograde cholangiopancreatography (ERCP) during the diagnostic work up period before treatment onset, and risk of complications were evaluated in patients with gallbladder cancer, intrahepatic-, perihilar- and distal cholangiocarcinoma. The risk of complications was compared depending on age, sex, comorbidity, in relation to stage and curative intent, endoscopy unit size, and with relation to survival.

RESULTS

Forty percent of the patients with biliary cancer underwent ERCP during the diagnostic workup, with variations depending on diagnosis. There was a 20% overall risk of periprocedural complications, a 9% risk of post-ERCP-pancreatitis (PEP), and a 6% risk of cholangitis. Increasing tumor stage did not increase risk, nor did comorbidity. The complication rates were slightly higher for younger patients and those undergoing curative treatment. For perihilar cholangiocarcinoma (pCCA) treated with curative intention, the risk of periprocedural complications was as high as 30.7%. No association between post-ERCP complications and survival was found.

CONCLUSION

Irrespective of type of biliary cancer, ERCP is frequently used during diagnostic workup. The complication risk indicates that primary biliary cancers are complication prone, regardless of stage. Notably the risk of complications was the highest for younger patients with low comorbidity scores, as well as for patients undergoing curatively aiming treatment.

Three-tiered critical care management of acute pancreatitis

INTRODUCTION AND AIMS

Acute pancreatitis (AP) can rapidly progress from a stable condition to multiple organ failure with high mortality. We aimed to describe the characteristics of AP patients requiring admission to a critical care facility and to identify predictors of disease progression.

METHODS

We conducted a post-hoc analysis using prospectively collected data from AP patients admitted to the high dependency unit (HDU) and intensive care unit (ICU) at the University of Pécs, Hungary, from 2016 to 2019. Patients were categorized according to critical care needs and severity. Daily records of organ function, organ support and laboratory parameters were kept. Descriptive analysis and predictive models were developed to forecast the need for escalated critical care and mortality.

RESULTS

Analysis of 92 cases (65 % male, mean age 63 (range 19-92) years) revealed a median critical care stay of 8 days (range 1-69) and a mortality rate of 47 %. Naive Bayes prediction models using admission C-reactive protein (CRP) and amylase levels achieved 75 % accuracy in predicting mortality and a 65 % probability of requiring HDU and/or ICU admission. CRP levels increased significantly (47 vs 62 mg/l, p: 0.015) from 48 to 24 h before critical care admission, contrasting with controls, resulting in significantly higher CRP levels in critical care patients (62 vs 32 mg/l, p: 0.007) 24 h before admission.

CONCLUSION

Our findings suggest that on-admission CRP and amylase cannot reliably predict progression of AP. However, elevated and increasing levels of CRP and amylase may indicate the need for early HDU admission to enable closer monitoring.

Is Minimally Invasive Surgery the Standard of Care for Ventral Hernia Repair?

When patients undergoing ventral or incisional hernia repair are reoperated for recurrence with an incidence rate of 16.0% following open repair and 18.8% following minimally invasive repair, it is time for re-evaluation of the real benefit of laparoscopy in ventral hernia repair.

Incisional Hernia in Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Single-Center Retrospective Study

BACKGROUND/OBJECTIVES

An incisional hernia (IH) is a frequent postoperative complication after cytoreductive laparotomic surgery for advanced ovarian cancer (AOC). It occurs in 2-22% of patients in the first two years of follow-up, depending on the series. Although different risk factors have been described for various types of malignancies and surgeries, few studies have analyzed the risk factors for hernia development in ovarian cancer (OC). However, none have examined the role of enhanced recovery after surgery (ERAS) programs.

METHODS

We performed a retrospective study that included patients with AOC and primary or interval debulking surgery through a median laparotomic approach. This study was conducted in Vall d'Hebron Hospital, Barcelona, Spain, between January 2015 and December 2022. Univariate and multivariate regression analyses were conducted.

RESULTS

Of the 156 patients included, 30 (19.2%) presented with an IH. The patients with IHs were smokers in a higher proportion to non-smokers (53.9% vs. 16.1%, p = 0.003) and more frequently presented with wound dehiscence (34.4% vs. 15.0%, p = 0.026). Patients in whom negative pressure wound therapy was applied had a hernia less frequently than those who had not had it (12.5% vs. 26.7%, p = 0.043). Similarly, the incidence of hernia decreased when patients went through an ERAS protocol (10.1% vs. 28.8%, p = 0.008). In the multivariate analysis, smoking was the only independent risk factor (RR 10.84, CI 2.76-42.64), and applying an ERAS protocol was seen to be the sole protective factor (RR 0.22, CI 0.08-0.61) against the development of an IH.

CONCLUSIONS

The implementation of ERAS is highly recommended due to its numerous benefits, most notably the reduction in hernia incidence. Additionally, the preoperative identification of current smokers provides an opportunity for smoking cessation and targeted respiratory prehabilitation, both of which further contribute to IH reduction.

A bionic 3D-printed hydrogel microneedle of composite mesh for abdominal wall defect repair

The use of mesh repair is a frequently employed technique in the clinical management of abdominal wall defects. However, for intraperitoneal onlay mesh (IPOM), the traditional mesh requires additional fixation methods, and these severely limit its application in the repair of abdominal wall defects. We drew inspiration from the adhesion properties of mussels for the present study, functionalized carboxymethyl cellulose (CMC) with dopamine (DA), and added polyvinyl alcohol (PVA) to the composite to further improve the wet adhesive ability of hydrogels. The CMC-DA/PVA hydrogel microneedles (MNs) were fabricated using an inverse molding technique, incorporating a 3D-printed thermoplastic polyurethane mesh to enhance mechanical strength. The tensile test and porcine skin adhesion test demonstrated that the hydrogel mesh exhibited satisfactory mechanical properties and adhesion in vitro, thus replacing the traditional fixed mesh in the treatment of rat full-thickness abdominal wall defects. The results of animal experiments revealed that the hydrogel mesh promoted the growth of new granulation tissue and inhibited inflammatory responses, thereby paving the way for a novel approach in treating full-thickness abdominal wall defects.

The learning curve for the Shouldice Repair: a pilot analysis of post-training specialized surgeons at the Shouldice Hospital

PURPOSE

The aim of the study was to evaluate operative time and postoperative complications of 4 post-training specialized surgeons.

METHODS

This was a pilot retrospective chart review to determine the learning curve of a Shouldice primary inguinal hernia repair (Shouldice Repair) of 4 post-training specialized surgeons, at the Shouldice Hospital. The first 300 Shouldice Repairs (early learning block) were compared to their 900-1,000 repairs as the primary operating surgeon (late learning block). Data was collected from the hospital's database. The learning curve was examined using cumulative sum analysis (CUSUM).

RESULTS

During the early learning block cases, the surgeons had a mean operating time of 59.2 ± 11.2 min. The late learning block cases had significantly reduced operative time (53.4 ± 10.5 min, p = 0.001). According to the CUSUM analysis all four surgeons had a plateau after 78 to 88 operations in terms of operative time. A nonsignificant reduction in the rate of reported recurrences (n = 16 vs. n = 0) and surgical site occurrences (haematoma, seroma, infection; n = 27 vs. n = 2) was found between the early and late learning block cases.

CONCLUSION

The operating time plateaued after 78-88 Shouldice Repairs for the 4 surgeons trained and working at the Shouldice Hospital. A nonsignificant trend towards fewer complications were noted among late learning block cases.

Indocyanine green fluorescence improves safety in laparoscopic cholecystectomy using the Fundus First technique: a retrospective study

Introduction

As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Methods

Data from all patients operated with LC at Sundsvall General Hospital before and after the implementation of routine ICG between 2016 and 2023 were analyzed.

Results

The study included 2,009 patients; 1,455 operated with ICG (ICG-group) and 549 without (comparison group). FF-LC was used in 94.9% of all operations. The groups were comparable regarding gender, BMI, age, presence of acute cholecystitis and proportion urgent/elective surgery. ICG was found to be safe, with similar 30-day complication rates between study groups. A lower conversion rate was seen in the ICG-group (1.2% vs. 3.3%, p = 0.001) and there was a non-significant reduction in readmissions (p = 0.054). In univariate analysis, ICG was associated with prolonged operation time, but this was not supported in multivariate analysis. Time to cholangiography was prolonged in the ICG-group in both univariate and multivariate analyses.

Discussion

ICG fluorescence is an adjunct that could improve the operative safety. Implementation of routine ICG fluorescence at this Swedish hospital was found to be safe and efficient, suggesting improvement in safety during FF-LC. Further studies are needed to see if ICG increases safety in LC.

Impact of invasive infections on clinical outcomes in acute pancreatitis: early predictive factors and implications for prophylactic anti-infective therapy

BACKGROUND

The use of antibiotic therapy in acute pancreatitis remains controversial and is currently recommended only for confirmed infections of peripancreatic necrosis. However, reliable early predictors of septic complications and unfavorable outcomes are substantially lacking.

METHODS

Patients with acute pancreatitis were retrospectively reviewed and divided into two groups: one with a septic course defined by pathogen detection [GERM(+)] and one without [GERM(-)]. After propensity score matching, both groups were compared regarding clinical outcomes. Early predictors of pathogen detection were evaluated by multivariate analysis.

RESULTS

424 patients with acute pancreatitis were included. After propensity score matching 123 GERM(-) patients were compared to 74 GERM(+) patients. GERM(+) patients demonstrated significantly worse clinical outcomes with higher rate of intensive care treatment (59.5% vs. 35.0%; p = 0.0011) and consecutive longer stay in intensive care unit (11.5 ± 25.2d vs. 3.0 ± 7.9d; p = 0.0007), longer in-hospital stay (26.8 ± 22.0d vs. 14.7 ± 15.0d; p = 0.0003) as well as worse results in the composite outcome length of in-hospital stay > 15d or death (67.6% vs. 31.7%; p < 0.0001). Prescence of ascites and elevated white blood cell count at the onset of acute pancreatitis were identified as significant predictive factors in the early disease associated with invasive infection and pathogen detection. The most frequently detected pathogens were commensals of the gastrointestinal tract, observed in 70.7% of the examined body fluids and 50.7% of the examined blood cultures.

CONCLUSIONS

Detection of pathogens is associated with unfavorable clinical outcomes in acute pancreatitis. The presence of ascites and elevated white blood cell count at onset of acute pancreatitis are significant predictive factors indicating the risk of invasive infection with relevant bacterial load. Thus, an aggressive, early anti-infective strategy against pathogens of intestinal origin should be considered in these cases and may improve patient outcomes.

Return to Sport After Partum in Patients With Diastasis of the Rectus Abdominis Muscles: Ultrasound Evaluation and Rehabilitation Protocol

BACKGROUND

Diastasis rectus abdominis is a condition in which the rectus abdominis muscles separate and move laterally, causing stretching of the linea alba tissue with weakness of the abdominal wall. Although it can lead to hernia of the abdominal viscera, diastasis rectus abdominis is not a hernia in itself. This condition is common among women during pregnancy and the postpartum period and can significantly affect their quality of life and their return to sports activity. Unfortunately, information on the incidence, risk factors, prevention, and treatment of diastasis rectus abdominis are limited.

METHODS

We conducted a pilot prospective observational study on 37 patients who practiced sports at high levels (at least 3 times a week with amateur/competitive competitions) who underwent ultrasound measurements of the distance between the rectus abdominis muscles at the level of the xiphoid process, supraumbilical, umbilical, and subumbilical at time (T0), after 2 months from the rehabilitation protocol (T1), and then after 4 months of rehabilitation protocol (T2) from approximately 3 months after giving birth, and we saw an early return to sport.

RESULTS

Our data analysis reveals that there is an initial decrease in diastasis during the first 2 months with 3 weekly physiotherapy activity sessions in all 4 measurements. One session takes place on site with physiotherapists, while the other 2 are carried out at home using the rehabilitation protocol provided by the medical staff. At the 4-month follow-up, the improvement was similar to the previous follow-up.

CONCLUSION

Of the 37 women analyzed, 6 were referred to the surgeon; 2 for hernias and 4 for diastases greater than 4 cm. The remaining women benefited from a conservative approach. Patients undergoing the rehabilitation protocol showed improvements in all 4 measures, as well as their early return to sport.

The association between physician sex and patient outcomes: a systematic review and meta-analysis

BACKGROUND

Some prior studies have found that patients treated by female physicians may experience better outcomes, as well as lower healthcare costs than those treated by male physicians. Physician-patient sex concordance may also contribute to better patient outcomes. However, other studies have not identified a significant difference. There is a paucity of pooled evidence examining the association of physician sex with clinical outcomes.

METHODS

This random-effects meta-analysis was conducted according to the PRISMA guidelines and prospectively registered on PROSPERO. MEDLINE and EMBASE were searched from inception to October 4th, 2023, and supplemented by a hand-search of relevant studies. Observational studies enrolling adults (≥ 18 years of age) and assessing the effect of physician sex across surgical and medical specialties were included. The risk of bias was assessed using ROBINS-I. A priori subgroup analysis was conducted based on patient type (surgical versus medical). All-cause mortality was the primary outcome. Secondary outcomes included complications, hospital readmission, and length of stay.

RESULTS

Across 35 (n = 13,404,840) observational studies, 20 (n = 8,915,504) assessed the effect of surgeon sex while the remaining 15 (n = 4,489,336) focused on physician sex in medical/anesthesia care. Fifteen studies were rated as having a moderate risk of bias, with 15 as severe, and 5 as critical. Mortality was significantly lower among patients of female versus male physicians (OR 0.95; 95% CI: 0.93 to 0.97; PQ = 0.13; I2 = 26%), which remained consistent among surgeon and non-surgeon physicians (Pinteraction = 0.60). No significant evidence of publication bias was detected (PEgger = 0.08). There was significantly lower hospital readmission among patients receiving medical/anesthesia care from female physicians (OR 0.97; 95% CI: 0.96 to 0.98). In a qualitative synthesis of 9 studies (n = 7,163,775), patient-physician sex concordance was typically associated with better outcomes, especially among female patients of female physicians.

CONCLUSIONS

Patients treated by female physicians experienced significantly lower odds of mortality, along with fewer hospital readmissions, versus those with male physicians. Further work is necessary to examine these effects in other care contexts across different countries and understand underlying mechanisms and long-term outcomes to optimize health outcomes for all patients.

REVIEW REGISTRATION

PROSPERO - CRD42023463577.

Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

BACKGROUND

The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode.

METHODS

We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome.

RESULTS

Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP.

CONCLUSION

Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles.

Risk Factor Analysis and Molecular Epidemiological Investigation of Carbapenem-Resistant Enterobacteriaceae (CRE) Infection in Patients with Acute Pancreatitis

Objective

Patients with acute pancreatitis (AP) complicated by carbapenem-resistant Enterobacteriaceae (CRE) infection often have a higher mortality rate. However, little investigation on the risk factor analysis has been published for the AP complicated by CRE. Therefore, this study conducted a retrospective analysis of the clinical characteristics, risk factors, and molecular epidemiological features associated with CRE infection in patients with AP.

Methods

A total of 240 patients with AP were admitted to our hospital from 2011 to 2021 as the research objects, and were divided into a CRE group of 60 cases and a non-CRE group of 180 cases based on whether they were co-infected with CRE or not. Furthermore, both univariate analysis and multivariate analysis were used to analyze the risk factors of AP co-infection with CRE. In the CRE group, polymerase chain reaction (PCR) and agarose gel electrophoresis (AGE) were used to detect the expression of five common carbapenemase genes including bla KPC, blaIMP, blaVIM, blaNDM , and blaOXA-48 .

Results

The pathogenic bacteria in the CRE group are composed of Klebsiella pneumonia at 35.00%, Escherichia coli at 33.33%, Enterobacter cloacae at 25.00%, and Citrobacter freundii at 6.67%. Multivariate analysis showed that APACHE-II scores (OR=1.22), history of abdominal surgery (OR=81.82), and ERCP (OR=3.66) were independent risk factors for AP co-infection with CRE (P<0.05). About half (18/40) of the CRE carried carbapenemase genes. bla KPC was the major carbapenemase gene.

Conclusion

There are many risk factors for AP co-infection with CRE, which can occur in patients with high APACHE-II scores, experienced ERCP, and a history of abdominal surgery.

Surgery for primary ventral hernias and risk of postoperative pain, nausea: a population-based register study

PURPOSE

The aim of this study was to evaluate risk factors for postoperative pain and nausea after open repair for primary ventral hernias.

METHOD

A population-based registry study was conducted based on data assembled from the Swedish national ventral hernia repair register between January 2016 and December 2021and cross-matched with the Swedish perioperative register.

RESULTS

Altogether 2064 open ventral hernia repairs were registered, including 816 (39.5%) performed on women. Of these, 91 (4.4%) were registered to suffer postoperative nausea or vomiting (PONV) and 403 (19.5%) postoperative pain (PP). In both univariable and multivariable logistic regression analyses, significant predictors of postoperative nausea and pain included male gender, which was associated with lower odds of both postoperative nausea (multivariable OR: 0.30, 95% CI: 0.18-0.49, P < 0.001) and postoperative pain (multivariable OR: 0.60, 95% CI: 0.44-0.83, P = 0.002). Additional predictors of postoperative nausea included emergency surgery (multivariable OR: 4.08, 95% CI: 1.10-15.08, P = 0.035), operative time > 40 min (multivariable OR: 4.15, 95% CI: 2.24-7.69, P < 0.001). Conversely total intravenous anesthesia was associated with lower incidence of PONV (multivariable OR: 0.40, 95% CI: 0.22-0.74, P = 0.003). Other factors, such as age, BMI, smoking status, ASA classification, hernia size, surgery type, operative time, and anesthesia type, were not significantly associated with postoperative pain after adjusting for other variables.

CONCLUSION

Postoperative nausea and vomiting (PONV) are significantly reduced with total intravenous anesthesia (TIVA) compared to inhalation anesthesia, with no notable difference in postoperative pain between the two methods.

Favorable 30-day outcomes of initial open inguinal hernia repair with local anesthesia among frail patients

BACKGROUND

Open inguinal hernia repair (OIHR) can be conducted under either general anesthesia (GA) or local anesthesia (LA). Despite a lack of evidence supporting improved perioperative outcomes, GA is the predominant anesthesia type used in OIHR. Frailty is defined as a clinically recognizable state of age-related increased vulnerability. This study aimed to compare the 30-day perioperative outcomes of frail patients undergoing OIHR with either GA or LA.

METHODS

Patients who underwent initial OIHR were identified in the ACS-NSQIP database from 2005-2021. Patients with a Modified Frailty Index (mFI)≥2 were included. Patients were divided based on GA or LA administered. Multivariable logistic regression was used to compare 30-day perioperative outcomes between frail patients undergoing OIHR under GA or LA.

RESULTS

Among 20,129 frail patients who underwent initial OIHR, 13,473 had GA, and 3686 had LA. The 30-day mortality rates for LA and GA were low. However, frail patients who underwent LA had a lower risk of bleeding (aOR 0.282, P=0.04), superficial surgical site infection (aOR 0.450, P=0.03), and discharge not to home (aOR 0.792, P<0.01). In addition, frail patients who underwent LA had shorter operation time (58.42±25.26 vs 67.60±37.17 mins, P<0.01) and a shorter length of stay (0.45±2.30 vs 0.57±2.96 days, P<0.01).

CONCLUSION

Although GA is the dominant anesthesia use (4:1) in OIHR among frail patients, LA emerges as a safe alternative to GA for these patients, offering potential benefits such as reduced complications and increased day-case surgery volume, which may be associated with decreased healthcare costs.

Improved outcomes after groin hernia surgery in Sweden between 1992 and 2021: Swedish Hernia Register

PURPOSE

Surgery for groin hernia is one of the most common operations in the world. Therefore, research concerning the outcomes of groin hernia surgery is extremely important both for the individual patient as well as for those providing the healthcare funding. The aim of this study is to evaluate the outcomes of hernia surgery in Sweden over a 30 year time period, from 1992 to 2021.

METHODS

All groin hernia repairs in the Swedish Hernia Register between 1992 to 2021 were analyzed with emphasis on the surgical method, reoperation rate for recurrence and date of surgery, specifically 1992-2001, 2002-2011 and 2012-2021. By using personal identification numbers, a cumulative reoperation rate has been deduced for males and females separately.

RESULTS

A total of 368,502 groin hernia operations identified in the Swedish Hernia Register between 1992 to 2021 were eligible for analysis. Since the register was begun, there have been significant changes in the choice of operative techniques, from suture repair in 1992 to open anterior mesh repair around the year 2000, until today, where an increasing proportion of hernias are repaired using laparo-endoscopic techniques. There has been a reduction in the reoperation rate for recurrence in both males and females, with the most pronounced improvement being seen in females. The laparo-endoscopic technique is associated with a reduced incidence of reoperation for recurrence in females.

CONCLUSION

Groin hernia surgery in Sweden has undergone substantial changes over the past 30 years. Reoperation for recurrence has decreased significantly during recent years, especially in females.

Sportsman's Hernia repair using Nesovic procedure, a 13-year single-center experience

Sportsman's hernia is very frequent in some sports, particularly in football. This painful syndrome is reported by high-level athletes as well as amateurs. There is no consensus about the management of sportsman's hernia, because of the heterogeneity in anatomoclinic forms. In case of surgical indication, the Nesovic procedure, also named "fasciomyoplasty", is one of the recommended procedures for the abdomino-parietal forms. Our objective was to report our experience with this procedure in terms of short- and mid-term results. All the patients who underwent Nesovic procedure between January 2009 and December 2022 in our center were retrospectively reviewed. 43 patients (98% men; mean age: 29.5 ± 9.2 years) were included. 37% of patients were professional athletes. The median time from symptoms' onset to diagnosis was 3 months (range = 1-72 months). The median time from diagnosis to surgery was 7 months (range = 1-58 months). Postoperative overall morbidity occurred in six patients (14%), including scrotum swelling (n = 2), hematoma (n = 1), serous collection (n = 1) and acute urinary retention (n = 2). No major complication occurred. At the end of follow-up (median: 1 year; range = 1 month-11 years), 84% of patients recovered their previous sports activity, after a mean delay of 2 months. Nesovic procedure is efficient in more than 80% of sports patients without any major morbidity.

[Vacuum-instillation laparostomy for gunshot peritonitis]

OBJECTIVE. T

O evaluate efficacy of vacuum instillation laparostomy in the treatment of victims with gunshot peritonitis.

MATERIAL AND METHODS

We analyzed treatment outcomes in 103 victims with gunshot abdominal wounds complicated by peritonitis. All patients underwent multi-stage surgical treatment with vacuum-instillation laparostomy (VIL) in the main group (n=37) and vacuum-assisted laparostomy (VAL) in the control group (n=66). Negative pressure was 90 mm Hg due to high risk of bleeding following traumatic disease. The interval between debridement did not exceed 48 hours. VIL was carried out in the following format: duration of vacuum phase 3 hours 30 minutes, volume of injected solution 300 ml, exposure time 30 minutes.

RESULTS

Complications occurred in 32.4% and 43.9% of patients, respectively (p>0.05). There was a tendency towards significant differences (p=0.07) in the incidence of complications Clavien-Dindo grade III-IV (13.5% and 30.3%). In-hospital mortality was 3% and 6%, respectively (p>0.05). Bacteriological analysis revealed faster achievement of target indicators of microflora elimination in VIL (the 7th day) compared to VAL (the 11th day). Adhesive process following VIL was significantly less severe. Indeed, there was Björck stage 1B and 2B of abdominal cavity by the 4th debridement in majority of patients in both groups, respectively. These changes correlated with histological findings. VIL was accompanied by faster regression of leukocyte infiltration and less severe fibrous changes.

CONCLUSION

VIL provides more effective abdominal decontamination and less severe adhesive process compared to VAL. This reduces the number of debridement procedures and risk of complications.

Laparoscopic Cholecystectomy in a Resource-Constrained Hospital in South Africa: Antibiotic Prophylaxis, Iatrogenic Perforation, Risk Factors, and Management

Introduction Iatrogenic gallbladder perforation is a notable complication of laparoscopic cholecystectomy. Despite its prevalence, optimal antibiotic prophylaxis strategies remain controversial. This study examines the use of antibiotics during laparoscopic cholecystectomy, evaluates the management of gallbladder perforations, and identifies associated risk factors. Method A retrospective analysis of 152 laparoscopic cholecystectomy patients at New Somerset Hospital was conducted, covering April 2021 to June 2023. Data collection included demographics, comorbidities, surgical indications, imaging findings, antibiotic regimens, and intraoperative and postoperative management of gallbladder perforations. Histological outcomes and complication management were also reviewed. Results Among the 152 patients, 86.85% (n=132) were female. Gallbladder perforation occurred in 55.9% (n=85). Spillage findings varied: bile alone (n=59), bile with stones (n=19), stones alone (n=3), pus (n=1), and stone with pus (n=1). Two patients had no spillage after iatrogenic perforation. Intraoperative management universally involved suction and lavage. Sixteen antibiotic protocols were documented, with 140 patients receiving preoperative, intraoperative, postoperative antibiotics, or combinations thereof. No infectious complications were reported. Age over 40 (65.2%, n=92) was a significant risk factor for perforation (p<0.05). Conclusion This study recommends a single preoperative dose of cefazolin to prevent infectious complications, even in cases of gallbladder perforation. Suction, washout, and retrieval of spilled stones are essential for managing perforations effectively. Establishing standardized antibiotic protocols could improve outcomes and reduce variability in clinical practice.

Sex hormone-binding globulin and its critical role in prostate cancer: A comprehensive review

Prostate cancer (PC) is a common and widespread cancer that affects men globally. A complicated interaction of hormonal variables influences its development. Sex hormone-binding globulin (SHBG) is a crucial element in controlling the availability of sex hormones, especially androgens, which have a notable impact on the development and progression of PC. SHBG controls the levels of free, active androgens in the body, which helps regulate androgen-dependent processes associated with PC. The equilibrium between SHBG and androgens plays a critical role in maintaining the stability of the prostate. When this balance is disrupted, it is associated with the development and advancement of PC. The processes responsible for SHBG's role in PC are complex and have multiple aspects. SHBG primarily binds to androgens, preventing them from interacting with androgen receptors (ARs) in prostate cells. It reduces the activation of androgen signaling pathways essential for tumor development and survival. In addition, SHBG can directly affect prostate cells by interacting with specific receptors on the cell surface. This review thoroughly examines the role of SHBG in PC, including its physiological activities, methods of action, and clinical consequences.

Predicting ERCP procedure time - the SWedish Estimation of ERCP Time (SWEET) tool

BACKGROUND

The duration of an endoscopic retrograde cholangiopancreatography (ERCP) is influenced by a multitude of factors. The aim of this study was to describe the factors influencing ERCP time and to create a tool for preintervention estimation of ERCP time.

METHODS

Data from 74 248 ERCPs performed from 2010 to 2019 were extracted from the Swedish National Quality Registry (GallRiks) to identify variables predictive for ERCP time using linear regression analyses and root mean squared error (RMSE) as a loss function. Ten variables were combined to create an estimation tool for ERCP duration. The tool was externally validated using 9472 ERCPs from 2020 to 2021.

RESULTS

Mean (SD) ERCP time was 36.8 (25.3) minutes. Indications with the strongest influence on ERCP time were primary sclerosing cholangitis and chronic pancreatitis. Hilar and intrahepatic biliary strictures and interventions on the pancreatic duct were the anatomic features that most strongly affected ERCP time. The procedure steps with most influence were intraductal endoscopy, lithotripsy, dilation, and papillectomy. Based on these results, we built and validated the SW: edish E: stimation of E: RCP T: ime (SWEET) tool, which is based on a 10-factor scoring system (e.g. 5 minutes for bile duct cannulation and 15 minutes for pancreatic duct cannulation) and predicted ERCP time with an average difference between actual and predicted duration of 17.5 minutes during external validation.

CONCLUSIONS

Based on new insights into the factors affecting ERCP time, we created the SWEET tool, the first specific tool for preintervention estimation of ERCP time, which is easy-to-apply in everyday clinical practice, to guide efficient ERCP scheduling.

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

[Vacuum-assisted laparostomy for diffuse postoperative peritonitis in patients with abdominal cancers]

OBJECTIVE

To improve the outcomes in patients with abdominal cancers complicated by diffuse postoperative peritonitis (DPP) using vacuum-assisted laparostomy (VAL) with elective staged peritoneal lavage.

MATERIAL AND METHODS

There were 141 patients with DPP: group I (63 patients) - VAL, group II (78 patients) - redo laparotomy on demand (RD). Negative pressure therapy was performed using commercial vacuum systems with vacuum dressing changes after 48 - 72 hours. We assessed mortality, morbidity, abdominal cavity status (Björck classification) and incidence of primary fascial closure of abdominal cavity.

RESULTS

There were 10 (15.9%) and 24 (30.8%) deaths, respectively (p=0.040). Complications Clavien-Dindo grade 3-5 were significantly more common in the 2nd group. According to the Björck classification, grades 2A (39.7%) and 2B (41.3%) became more common after the 2nd peritoneal lavage in the 1st group. After the 3rd and further staged peritoneal lavages, «frozen open abdomen» (grade 3A and 4) prevailed. This classification revealed significant correlations with abdominal index, intra-abdominal hypertension and C-reactive protein. Primary fascial closure of abdominal cavity was performed in 40 (63.5%) patients in the 1st group.

CONCLUSION

Vacuum-assisted laparostomy is effective for diffuse postoperative peritonitis compared to on-demand relaparotomy. This approach provides lower mortality and morbidity rates, as well as better control over local inflammatory process and intra-abdominal pressure.

Evaluating Surgical Outcomes in Acute Cholecystectomies

Background and Objectives

This study aimed to identify the predictors of surgical outcomes in acute cholecystitis (AC).

Methods

Patients undergoing cholecystectomy for AC between January 1, 2007 and December 31, 2019 at a single center were retrospectively reviewed. Conversion rate (CR), laparoscopic success rate (LSR), mortality, and bile duct injury (BDI) were evaluated in light of sex, age, ultrasound morphological diagnoses, severity of cholecystitis, performance status, time frame, and introduction of percutaneous transhepatic gallbladder drainage (PTGBD).

Results

A total of 465 patients underwent early cholecystectomy. CR and LSR were 16.89% and 78.28%, respectively; the mortality rate was 1.62%. Increased severity of cholecystitis (grade I vs II vs III) was associated with increased mortality (1.17 vs 2.27 vs 8.33%, P = .183) and CR (7.09 vs 32.93 vs 28.57%, P < .001) and decreased LSR (91.11 vs 61.11 vs 38.46%, P < .001). Surgery within 72 hours had lower mortality (1.41 vs 2.6%, P = .613) with significantly lower CR (14.45 vs 25.71%, P = .008) and higher LSR (81.69 vs 67.53%, P = .008) compared to surgery after 72 hours. Mortality (0 vs 0.92 vs 6.19%, P = .001) and CR (4.2 vs 16.27 vs 39.53%, P < .001) increased with an increase in Charlson comorbidity index (CCI), while LSR decreased (95.8 vs 79.91 vs 50.49%, P < .001).

Conclusion

CCI and the severity of cholecystitis had the strongest influence on CR and LSR. Cholecystectomies performed within 72 hours were associated with reduced CR and increased LSR. PTGBD is a viable treatment option in elderly high-risk patients.

[Evaluation of Exposure Dose Reduction Effect for Cone-beam Computed Tomography with Bismuth Sheet in Image-guided Radiation Therapy of Prostate Cancer]

PURPOSE

Image-guided radiation therapy using cone-beam computed tomography (CBCT) for prostate cancer is problematic due to the increasing exposure dose at each treatment session. This study aimed to evaluate the effect of exposure dose reduction using bismuth sheets for pelvic CBCT.

METHODS

Using a radiophotoluminescence dosimeter (GD-352M) and CBCT imaging conditions with three X-ray tube rotation angles (292°-88°, 92°-248°, and 92°-88°), absorbed doses were measured in the rectum, anterior and posterior bladder walls, right and left pelvic subcutaneous at 5 cm superior the prostate center of the pelvic phantom and in a testis. Next, the same measurements were performed when these measurement points were covered with a bismuth sheet.

RESULTS

The absorbed doses at 92°-248° with the bismuth sheets were reduced by 31.3% from 16.3±0.2 mGy to 11.2±0.2 mGy for the rectum and by 57.1% from 45.0±2.7 mGy to 19.3±1.0 mGy for the testis, which were the lowest among the imaging conditions. Although the anterior and posterior bladder walls were the highest dose at 48.7±11.5 and 20.2±0.4 mGy, the high reduction rates of 42.0% and 36.9%, respectively.

CONCLUSION

From the viewpoint of the exposure risk to the bladder, rectum, and testis, using bismuth sheets and the X-ray tube rotation angle of 92°-248° effectively reduced the exposure dose.

[Unplanned redo surgeries after appendectomy characterizing the quality of acute appendicitis management]

OBJECTIVE

To study the effect of appendectomy technique on the incidence, causes and features of redo surgeries after appendectomy.

MATERIAL AND METHODS

Appendectomies were performed in 1114 patients. Repeated interventions were necessary in 19 (1.4%) people (10 (2.0%) patients after laparoscopic appendectomy and 9 (1.5%) patients after open surgery). Structure, surgical features and results are estimated.

RESULTS

There were 505 (45.3%) laparoscopic and 609 (54.7%) open appendectomies. Repeated interventions were performed in 10 (0.9%) and 9 (1.5%) cases, respectively. The causes of repeated surgeries were abdominal infectious complications in 7 (0.6%) cases, intra-abdominal bleeding in 5 people (0.4%), abdominal wall infection in 3 (0.3%) cases, eventeration in 4 (0.35%) cases, undiagnosed intestinal obstruction during index surgery in 1 patient (0.1%) and severe abdominal pain in 1 patient (0.1%). There were complications Clavien-Dindo grade IIIA-IIIB. There were no fatal outcomes. In 2023-2024, 286 laparoscopic appendectomies were performed including 2 (0.69%) repeated interventions. The number of laparoscopic interventions throughout this period exceeded the number of open appendectomies by 2.4 times and amounted to 81.7% of all appendectomies. Repeated interventions after traditional appendectomy were performed in 2 patients (3.1%).

CONCLUSION

Predominant laparoscopic appendectomies in recent years improved the quality of care for patients with acute appendicitis regarding redo surgeries. Acceptable incidence of repeated interventions indicates sufficient institutional experience in the treatment of acute appendicitis.

Shall We Not Pressurize It? Effects of Bone Cement Pressurization on Mortality and Revision After Hip Hemiarthroplasty for Neck of Femur Fracture Patients: A Comparative Cohort Study

OBJECTIVES

This study aimed to compare 30-day postoperative mortality, and revision for aseptic femoral component loosening and all-causes after hip hemiarthroplasty, performed with or without pressurization of the bone cement, in patients with neck of femur fracture.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from December 10, 2007 (database inception) to November 15, 2023 (search date) were reviewed.

OUTCOME MEASURES AND COMPARISONS

Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurization of the bone cement for outcomes 30-day postoperative mortality, revision for aseptic femoral component loosening, and revision for all-causes.

RESULTS

There were 406 procedures among 402 patients, and 722 procedures among 713 patients that were performed with and without pressurization of the bone cement, respectively. Mean ages were 83.1 and 84.3 years ( P = 0.018), with 72.2% and 68.6% ( P = 0.205) women in the pressurized and non-pressurized cement patient groups, respectively. There were no differences in 30-day postoperative mortality (7.2% vs. 8.2%; HR 0.89, 95% CI 0.46-1.73, P = 0.727). There were no differences in all-cause revision (HR 1.04, 95% CI 0.27-4.04, P = 0.953). No revisions were performed for aseptic loosening. Survival at 10 years postoperatively was 15.3% (95% CI 11.46-19.64) and 12.6% (95% CI 7.67-18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurization, respectively.

CONCLUSIONS

There were no differences in 30-day postoperative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurization. Bone cement pressurization did not confer any advantages for revision outcomes that may be attributed, in part, to patients' high mortality rate and low survival beyond 10 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for surgical site infections following hepatobiliary surgery: An umbrella review and meta-analyses

BACKGROUND

In the hepatobiliary (HPB) surgical cohort, surgical site infections (SSI) can extend hospital stays, result in higher morbidity, and poor patient outcomes. This umbrella review and meta-analysis aimed to synthesise the evidence for the association between clinical and patient risk factors and SSI in patients following HPB surgery.

METHODS

We searched MEDLINE, CINAHL, EMBASE and Scopus from January 2000 to April 2023 to identify systematic reviews and meta-analyses where patient and/or clinical factors of SSIs following HPB surgery were reported. The summary effect size, its 95 % CI and the 95 % PI were calculated for each meta-analysis using random-effects models. 30-day cumulative SSI incidence was presented as the pooled estimate with 95 % CIs. Between-study heterogeneity was explored using the I2 statistic.

RESULTS

Nine systematic reviews and meta-analyses were included. Our findings suggest open surgical approach, type of pancreas procedure, preoperative biliary drainage, older age, male sex and high BMI (>25mg/k2) as statistically significant factors for increasing a patient's risk of SSI following HPB surgery. The cumulative incidence of SSI in the HPB cohort of 43,296 was 11 % (95 % CI 6%-20 %), with substantial variation between the reviews.

CONCLUSION

We identified several patient and clinical factors, however only one was graded as a high level of evidence.

Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

We aimed to compare enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE) in terms of safety and efficacy in post-Roux-en-Y gastric bypass patients. We conducted a rigorous analysis based on a predefined protocol (PROSPERO, CRD42022368788). Sixty-seven studies were included. The technical success rates were 77% (CI 69-83%) for EA-ERCP, 93% (CI 91-96%) for LA-ERCP, and 96% (CI 92-98%) for EDGE. Subgroup differences were significant between the EA-ERCP and other groups (p < 0.05). The overall adverse event rates were 13% (CI 8-22%), 19% (CI 14-24%), and 20% (CI 12-31%), respectively (p = 0.49). Our findings suggest that EDGE and LA-ERCP may be more effective and as safe as EA-ERCP.