Short-term outcomes of minimally invasive techniques in posterior component separation for ventral hernia repair: a systematic review and meta-analysis

INTRODUCTION

The objective of this study was to perform a systematic review and meta-analysis to summarize various approaches in performing minimally invasive posterior component separation (MIS PCS) and ascertain their safety and short-term outcomes.

METHODS

A systematic literature searches of major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify studies that provided perioperative characteristics and postoperative outcomes of MIS PCS. Primary outcomes for this study were: surgical site events (SSE), surgical site occurrence requiring procedural intervention (SSOPI), and overall complication rates. A random-effect meta-analysis was conducted which allows computation of 95% CIs using simple approximation and incorporates inverse variance method with logit transformation of proportions.

RESULTS

There were 14 studies that enrolled 850 participants that were included. The study identified rate of SSE, SSOPI, and overall rate of complications of all MIS TAR modifications to be 13.4%, 5.7%, and 19%, respectively.

CONCLUSIONS

Our study provides important information on safety and short-term outcomes of MIS PCS. These data can be used as reference when counseling patients, calculating sample size for prospective trials, setting up targets for prospective audit of hernia centers. Standardization of reporting of preoperative characteristics and postoperative outcomes of patients undergoing MIS PCS and strict audit of the procedure through introduction of prospective national and international registries can facilitate improvement of safety of the MIS complex abdominal wall reconstruction, and help in identifying the safest and most cost-effective modification.

Systematic review and meta-analysis comparing ventral hernia repair using minimally-invasive extended totally extraperitoneal repair versus intraperitoneal onlay mesh repair

BACKGROUND

This systematic review and meta-analysis analysed was set up to compare totally extraperitoneal mesh repair (TEP) and intraperitoneal onlay mesh placement (IPOM) in patients undergoing minimally invasive ventral hernia mesh surgery (MIS-VHMS).

METHODS

A systematic literature searches of three major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify studies that compared two techniques of MIS-VHMS: TEP and IPOM. Primary outcome of interest was major complications post-operatively, defined as a composite outcome of surgical-site occurrences requiring procedural intervention (SSOPI), readmission to hospital, recurrence, reoperation or death. Secondary outcomes were intraoperative complications, duration of surgery, surgical site occurrence (SSO), SSOPI, postoperative ileus, post-operative pain. The risk of bias was assessed using Cohranes Risk of Bias tool 2 for randomized controlled trials (RCTs) and Newcastle-Ottawa score for observational studies (OSs).

RESULTS

Five OSs and two RCTs al including total number of 553 patients were included. There was no difference in primary outcome (RD 0.00 [-0.05, 0.06], p=0.95), incidence of postoperative ileus. Operative time was longer in TEP (MD 40.10 [27.28, 52.91], p<0.01). TEP was found to be associated with less postoperative pain at 24h and 7days after surgery.

CONCLUSIONS

Both TEP and IPOM were detected to have equal safety profile and do not differ in SSO or SSOPI rates, incidence of postoperative ileus. TEP has longer operative time but provides better early postoperative pain outcomes. Further high-quality studies with long follow up evaluating recurrence and patient reported outcomes are needed. Comparison of other transabdominal and extraperitoneal MIS-VHMS techniques is another direction of future research. PROSPERO registration: CRD4202121099.

Prolonged thromboprophylaxis with rivaroxaban after bariatric interventions: single centre experience

BackgroundVenous thromboembolism (VTE) is common after bariatric surgery and extended prophylaxis is generally recommended. Low molecular weight heparin is the most commonly used agent but requires patients to be trained to self-inject and is expensive. Rivaroxaban is an oral daily formulation approved for VTE prophylaxis after orthopedic surgery. Efficacy and safety of rivaroxaban has been confirmed in major gastrointestinal resections by several observational studies. We report a single centre experience of using rivaroxaban as an agent for VTE prophylaxis in bariatric surgery. MethodsWe performed prospective cohort study assessing safety and efficacy of rivaroxaban as a medication for VTE prophylaxis in patients undergoing bariatric surgery in a single centre in Kyiv, Ukraine. Patients undergoing major bariatric procedure received perioperative prophylaxis of VTE with subcutaneous low molecular weight heparin and then were switched to rivaroxaban for total of 30 days starting on the 4th postoperative day. Thromboprophylaxis was performed in accordance with the VTE risks derived from the Caprini score. On the 3rd, 30th, 60th day after the operation, the patients underwent ultrasound examination of the portal vein, as well as the veins of the lower extremities. Telephone interviews were conducted 30 and 60 days after the surgery to evaluate the presence of complaints which may be characteristic for VTE as well as to assess compliance with the regimen and to assess patient satisfaction. Outcomes studies were incidence of VTE and adverse events related to rivaroxaban administration.Results110 patients were included in the study from July 2019 to May 2021. The average age of the patients was 43.6 years, the average preoperative BMI was 55 (35 to 75). One hundred and seven patients (97.3%) underwent laparoscopic intervention while three patients (2.7%) underwent laparotomy. Eighty-four patients underwent sleeve gastrectomy and twenty-six patients underwent other procedures, including bypass surgery. Average calculated risk of thromboembolic event was 5-6% based on Caprine index. All patients were treated with extended prophylaxis with rivaroxaban. The average follow-up period for patients was 6 months. There were no clinical or radiological evidence of thromboembolic complications in the study cohort. Overall complication rate was 7.2%, however, only one patient (0.9%) developed subcutaneous hematoma associated with rivaroxaban not requiring intervention. ConclusionExtended postoperative prophylaxis with rivaroxaban is safe and effective in preventing thromboembolic complications in patients undergoing bariatric surgery. It is preferred by patients and further studies should be considered to further evaluate its use in bariatric surgery.

Systematic review and meta-analysis of randomized controlled trials evaluating the effect of the level of ligation of inferior mesenteric artery on functional outcomes in rectal cancer surgery

BACKGROUND

This systematic review and meta-analysis studied the role of high (HL) versus low (LL) inferior mesenteric artery (IMA) ligation on genitourinary and defecatory dysfunction in patients who had undergone resection for rectal cancer (RC).

METHODS

A systematic literature search of four major databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) comparing HL and LL of IMA in RC surgery were identified. Those studies that looked at genitourinary or defecatory dysfunction were included. Random-effects modeling to summarize statistics was performed. The risk of bias was assessed using Cochrane's Risk-of-Bias tool 2.

RESULTS

Three RCTs were included. There was clinical heterogeneity with regard to cancer stage and location as well as operative techniques and adjuvant treatments. Functional outcomes (FO) that were reported by at least two studies were International Consultation on Incontinence Questionnaire (ICIQ), International Index for Erectile Function (IIEF), Jorge-Wexner incontinence score (J-W). Difference was observed in ICIQ at 9 months after surgery favoring LL (standard mean difference: - 0.66; 95% confidence intervals (CI): - 0.92, - 0.40; P = 0.37; I 2 = 0%). Difference was also observed in IIEF at 9 months favoring LL (mean difference: 7.43; CI: 1.86, 13.00; P = 0.16; I 2 = 50%).

CONCLUSIONS

Although our study has demonstrated the superiority of LL in genitourinary function preservation, these results should be taken with consciousness due to significant heterogeneity between included studies, small sample size, and potential bias. More high-quality studies are needed.

PROSPERO

CRD4202121099  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021210998.

Fascial defect closure versus bridged repair in laparoscopic ventral hernia mesh repair: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Several studies have examined effectiveness of primary fascial defect closure (FDC) versus bridged repair (no-FDC) during laparoscopic ventral hernia mesh repair (LVHMR). The purpose of this study was to systematically review and meta-analyse randomized controlled trials (RCTs) which compared safety and effectiveness of two techniques.

METHODS

Systematic literature searches (EMBASE, MEDLINE, PubMed, and CINAHL) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using predefined terms. RCTs comparing FDC and no-FDC in LVHMR were identified and retrieved. Primary outcomes were risk of recurrence and risk of major complications analyzed as a single composite outcome. Secondary outcomes were risks of seroma formation, clinical or radiologically confirmed eventration, incidence of readmission to hospital, postoperative changes in quality of life (QoL), and postoperative pain. Random effects modeling to summarize statistics were performed. The risk of bias was assessed using Cohrane's Risk of Bias tool 2.

RESULTS

Three RCTs that enrolled total of 259 patients were included. There was clinical heterogeneity present between studies related to patients' characteristics, hernia characteristics, and operative techniques. There was no difference found in primary outcomes, risks of seroma formation, eventration, and chronic pain. There is conflicting evidence on how both techniques affect postoperative QoL or early postoperative pain.

CONCLUSIONS

Both techniques were detected to have equal safety profile and do not differ in risk of recurrence, seroma formation, risks of clinical or radiological eventration. Giving uncertainty and clinical equipoise, another RCT examining FDC vs no-FDC laparoscopic mesh repair separately for primary and secondary hernias using narrow inclusion criteria for hernia size on well-defined population would be ethical and pragmatic.

PROSPERO REGISTRATION

CRD42021274581.

Implementation of extended prolonged venous thromboembolism prophylaxis with rivaroxaban after major abdominal and pelvic surgery - overview of safety and early outcomes

<b>Purpose: </b>Venous thromboembolism (VTE) after colorectal surgery is a well-documented complication, resulting in a general recommendation of extended post-discharge prophylaxis. Rivaroxaban, a factor Xa inhibitor, is a daily tablet approved for treatment of VTE and prophylaxis after orthopedic surgery. <br><b>Aim: </b>The purpose of this study is to evaluate the safety of rivaroxaban for extended prophylaxis after major abdominal and pelvic surgery. <br><b>Methods: </b>This is a retrospective review of patients undergoing major colorectal surgery at a regional hospital in Kiev, Ukraine. Patients received peri-operative VTE prophylaxis with subcutaneous heparin and then transitioned to rivaroxaban for a total of 30 days. Occurrences of major or minor bleeding, blood transfusion, and a need for re-intervention were noted. Phone surveys were administered on post-operative day 30 to assess compliance and satisfaction with the regimen. <br><b>Results: </b>A total of 51 patients were included in the study with an average age of 62.4 years. Seventy-one percent of the cases were abdominal, 29% were pelvic cases and 59% were done laparoscopically. There was one episode of major intra-abdominal bleeding requiring return to the operating room. There were 2 minor bleeding episodes which did not require intervention. There were no VTE events in the group. The phone survey response rate was 100%. All but one patient reported having completed the full course of rivaroxaban. Patients reported that oral prophylaxis was easy to adhere to and preferable compared to injections. <br><b>Conclusion: </b>Implementation of extended prophylaxis with rivaroxaban is easy, safe and does not increase rates of postoperative bleeding.

Biological welding - novel technique in the treatment of esophageal metaplasia

<b>Introduction:</b> Biological welding - controlled action of high frequency current on living tissues, which leads to their structural changes and weld formation - connection with unique biological properties (strength, high elasticity, insensitivity to microbial infection, stimulating effect on the regeneration process, speed and quality which surpasses the normal uncomplicated healing) [22]. This method is used in various fields of surgery, but at the moment there is no data on its use in case of esophageal cylindrocellular (intestinal) metaplasia (further esophageal metaplasia or Barrett's esophagus). <br><b>Objective:</b> The goal of this study is to evaluate biologic welding as a treatment option for patients with Barrett's esophagus. <br><b>Materials and methods:</b> Single-center retrospective review of patients with short-segment Barrett's esophagus and metaplasia were treated by argon plasma coagulation (APC) or Paton's welding. This was followed by Nissen fundoplication. Primary outcome of this study was mucosal healing with morphological confirmation of the absence of metaplasia. The groups included patients with a short segment of the esophagus Barrett's C2-3M3-4 (Prague Classification 2004) and high dysplasia without nodule formation in combination with hiatal hernia (VI World Congress of the International Society for Esophageal Diseases; ISED) [23-25]). <br><b>Results:</b> A total of 49 patients were included in the study with 25 patients treated by APC laser and 24 by biowelding. Four patients (16.0%) in the APC group developed stenosis and 5 patients (20.0%) developed recurrence compared to none in the biowelding group. Patients in the biowelding group had a significantly faster rate of mucosal healing leading to faster progression to Nissen fundoplication (at average 53 days) compared to APC laser group (surgery at 115 days). <br><b>Conclusions:</b> Biological welding of Paton's is a safe and effective treatment option for patients with esophageal metaplasia.

Antireflux surgery is required after endoscopic treatment for Barrett's esophagus

<b>Introduction:</b> Barrett's esophagus is an acquired condition that develops as a result of transformation of normal stratified squamous epithelium in the lower part of the esophagus into columnar epithelium. Barrett's esophagus is considered to be a complication of gastroesophageal reflux disease (GERD). Various endoscopic techniques have been shown to be successful in the treatment of this condition. However, long-term success in preventing further esophageal dysplasia is not clear. Biological welding consists in the application of controlled high-frequency current on living tissues and has been used to stop gastrointestinal bleeding, similarly to the APC technique which involves ablation of small intestinal metaplasia of the esophageal mucosa.<br/> <b>Aim:</b> The goal of this study was to evaluate the effectiveness of endoscopic techniques in the treatment of Barrett's esophagus and verify the need for a subsequent surgical intervention in patients with GERD complicated by Barrett's esophagus. <br/><b> Material and methods: </b> Patients with Barrett's esophagus C1-3M2-4 (Prague classification from 2004) and high dysplasia without nodules, as well as patients with confirmed GERD without hiatal hernia, were included in this study. Endoscopic treatment was performed with the use of argonoplasmic coagulation (APC) and high-frequency welding of living tissues (HFW). After the examination the patients were re-examined. Patients with recurrence of metaplasia and high DeMeester score (˃ 100) underwent antireflux surgery - crurography and Nissen fundoplication with creation of a soft and short cuff.<br/><b>Results:</b> A total of 89 patients were included in the study, 81 of whom were reexamined after ablation of Barrett's esophagus.In 12 patients, a recurrence of intestinal metaplasia resembling the small intestine was identified. Implementation of two-stage treatment was required for 9 patients - it involved a second procedure of ablation of the esophagus, followed by antireflux surgery. Surgical treatment was refused by 3 patients, who underwent only the second ablation procedure. All patients received drug therapy, consisting of prokinetics and proton pump inhibitors. Esophageal pH monitoring was repeated 3 months after surgery, showing normalization of the DeMeester score. As a result, the patients experienced no complaints such as heartburn, chest pain or dysphagia, which significantly improved their quality of life. Esophagogastroduodenoscopy and biopsy of the mucous membrane of the lower third of the esophagus were performed in accordance with the Seattle Protocol. After examining histological specimens, no regions of metaplasia were identified. <br/><b>Conclusion:</b> Antireflux surgery is required as a part of the treatment for Barrett's esophagus, which prevents further dysplasia and development of esophageal cancer.<br/&gt.