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Objective: Single-incision laparoscopic surgery has emerged as a safe and less invasive approach to conventional multi-port laparoscopy. The present meta-analysis aimed to assess the collective outcomes of single-incision laparoscopic gastrectomy (SILG) compared to multi-port laparoscopic gastrectomy (MLG) for gastric cancer. Methods: A PRISMA-compliant systematic review of randomized controlled trials (RCTs) that compared SILG and MLG for gastric cancer in PubMed and Scopus through January 2023 was conducted. The main outcomes of the review were complications, postoperative pain, conversion to open surgery, hospital stay, and recovery. Results: Three RCTs including 301 patients (61.8% male) were included. A total of 151 patients underwent SILG, and 150 underwent MLG. SILG was associated with a shorter operative time (WMD = −16.39, 95% CI: −27.38 to −5.40, p = 0.003; I2 = 0%) and lower pain scores at postoperative day 3 (WMD = −1.18, 95% CI: −2.27 to −0.091, p = 0.033; I2 = 99%) than MLG. There were no statistically significant differences between the two groups in estimated blood loss (WMD = –16.95, 95% CI: −35.84 to 1.95, p = 0.078; I2 = 82%), complications (OR = 0.71, 95% CI: 0.36 to 1.42, p = 0.337; I2 = 0%), conversion to open surgery (OR = 0.33, 95% CI: 0.01 to 8.38, p = 0.504), hospital stay (WMD = 0.72, 95% CI: −0.92 to 2.36, p = 0.056; I2 = 84%), time to first flatus (WMD = 0.06, 95% CI: −0.14 to 0.26, p = 0.566; I2 = 0%), time to first defecation (WMD = −0.14, 95% CI: −0.46 to 0.18, p = 0.392; I2 = 0%), or time to first oral intake (WMD = 0.37, 95% CI: −0.75 to 1.49, p = 0.520; I2 = 94%). Conclusions: SILG is associated with shorter operative times and less early postoperative pain than MLG. The odds of complications, blood loss, hospital stay, and gastrointestinal recovery were similar between the two procedures.

Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.

This review aimed to illustrate the types, limitations, and possible alternatives of peer review (PR) based on a literature review together with the opinions of a social media audience via Twitter. This study was conducted via the #OpenSourceResearch collaborative platform and combined a comprehensive literature search on the current PR system with the opinions of a social media audience of surgeons who are actively engaged in the current PR system. Six independent researchers conducted a literature search of electronic databases in addition to Google Scholar. Electronic polls were organized via Twitter to assess surgeons’ opinions on the current PR system and potential alternative approaches. PR can be classified into single-blind, double-blind, triple-blind, and open PR. Newer PR systems include interactive platforms, prepublication and postpublication commenting or review, transparent review, and collaborative review. The main limitations of the current PR system are its allegedly time-consuming nature and inconsistent, biased, and non-transparent results. Suggestions to improve the PR process include employing an interactive, double-blind PR system, using artificial intelligence to recruit reviewers, providing incentives for reviewers, and using PR templates. The above results offer several concepts for possible alternative approaches and modifications to this critically important process.

Background: Pelvic neurogenic and presacral tumors represent an uncommon, yet a challenging condition. The present study aimed to review the baseline clinicopathologic characteristics and treatment outcome of presacral and sacral neurogenic tumors treated in our institution. Methods: This was a retrospective cohort study of prospectively maintained data of consecutive patients with pelvic neurogenic tumors who underwent surgical treatment at a tertiary referral center between January 2006 and May 2021. Main outcome measures were the demographic characteristics of patients, tumor characteristics, type of surgical treatment, and outcomes, which comprised tumor recurrence and complications. Results: The present study included 43 (55.8% males) patients of a median age of 50 years. The majority of patients had iliac, presacral, or sacral tumors. The most frequent pathology was chordoma (27.9%), schwannoma (27.9%), neuroblastoma (13.9%), and neuroectodermal tumors (13.9%). Overall, 48.8% of tumors were malignant. Fourteen postoperative complications were recorded in 12 patients (27.9%; 95%CI: 15.3–43.7%). After a median follow-up of 30 months, tumor recurrence was recorded in 9 patients (20.9%; 95%CI: 10–36%). The median time to recurrence was 11 months. Patients with recurrence were mostly female and underwent more extensive surgical treatment. Conclusions: Pelvic neurogenic and presacral tumors tend to affect middle-aged individuals with a slight male predominance. Approximately half of pelvic neurogenic tumors are benign with Schwannoma being the most common benign tumor. The mid-term recurrence rate was 20% and female patients were more prone to develop recurrence.

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities. The operation time was 45 minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair.

BACKGROUND: The method of mesh fixation in Lichtenstein hernia repair may have an impact on the incidence of chronic groin pain (CGP) after surgery. This study aimed to compare fixation of mesh with N-butyl 2-cyanoacrylate and with sutures in open inguinal hernia repair in terms of CGP, postoperative complications, operation time, and hernia recurrence. PATIENTS AND METHODS: Adult patients with unilateral uncomplicated inguinal hernia were randomly assigned to one of two equal groups. Group I underwent mesh fixation with cyanoacrylate glue and Group II underwent mesh fixation with polypropylene sutures. The main outcome measures were pain scores at 1, 6, and 12 months of follow-up, hernia recurrence, postoperative complications, and operation time. RESULTS: Forty patients (39 male) of an average age of 48.2 years were included in the study. Patients in Group I had significantly lower pain scores at 1 week and 6 and 12 months after surgery than Group II. The operation time in Group I was significantly shorter than Group II (51.7 vs. 58.7 min, P = 0.007). No recurrence of hernia was recorded in either group at 12 months. Four patients in Group I experienced complications as compared to two patients in Group II with no significant difference (P = 0.66). CONCLUSIONS: Fixation of mesh in Lichtenstein repair with cyanoacrylate glue conferred significantly lower pain scores in the early postoperative period and at 6 and 12 months of follow-up than the classical suture fixation. No difference in the hernia recurrence and postoperative complication rates between cyanoacrylate and suture mesh fixation groups was observed.

Repair of inguinal hernia is one of the most common procedures in general surgical practice. Amyand's hernia is an unusual condition that entails the presence of the appendix in the hernial sac. In this case, we present a rare combination of Type II Amyand's hernia and sliding hernia that was discovered during elective hernial repair in a male patient. The inflamed appendix was removed, and tension-free Lichtenstein repair was performed. Postoperative recovery was uneventful with no recorded complications or recurrence of hernia. Amyand's hernia is usually diagnosed intraoperatively. The association of a sliding component with Amyand's hernia did not alter the management plan. The use of synthetic mesh in Type II Amyand's hernia is safe and feasible, despite the recommendation to avoid prosthetic repair in this type of hernia.

Abstract Background: Conservative treatment of chronic anal fissure (CAF) is the first line of treatment. Patients who fail conservative treatment are offered surgical treatment in the form of lateral internal sphincterotomy (LIS) or V-Y anoplasty.Objective: This prospective study aimed to compare LIS and V-Y anoplasty in the treatment of CAF based on the baseline resting anal pressure of patients.Methods: Female patients with CAF were investigated with anal manometry. Patients with elevated resting anal pressure were treated with LIS and patients with normal or low resting anal pressure were treated with V-Y anoplasty. Data about healing of anal fissure, reduction in pain score, continence disturbance, and complications were recorded on follow-up.Results: Twenty-four female patients of a mean age of 37.6 years were included to this study. Sixteen patients underwent LIS (group I) and 8 underwent V-Y flap (group II). Both groups achieved comparable time to complete healing. Both groups showed significant decrease in pain score at 3 months of follow-up (Group I: 6.1±0.85 to 0.93±0.7, p

Abstract Background: Conservative treatment of chronic anal fissure (CAF) is the first line of treatment. Patients who fail conservative treatment are offered surgical treatment in the form of lateral internal sphincterotomy (LIS) or V-Y anoplasty.Objective: This prospective study aimed to compare LIS and V-Y anoplasty in the treatment of CAF based on the baseline resting anal pressure of patients.Methods: Female patients with CAF were investigated with anal manometry. Patients with elevated resting anal pressure were treated with LIS and patients with normal or low resting anal pressure were treated with V-Y anoplasty. Data about healing of anal fissure, reduction in pain score, continence disturbance, and complications were recorded on follow-up.Results: Twenty-four female patients of a mean age of 37.6 years were included to this study. Sixteen patients underwent LIS (group I) and 8 underwent V-Y flap (group II). Both groups achieved comparable time to complete healing. Both groups showed significant decrease in pain score at 3 months of follow-up (Group I: 6.1±0.85 to 0.93±0.7, p

Background: Excisional hemorrhoidectomy is one of the most commonly performed anorectal procedures. Despite the satisfactory outcomes of excisional hemorrhoidectomy, the pain perceived by the patients following the procedure can be a distressing sequel. This review aimed to search the current literature for the existing evidence on how to avoid or minimize the severity of post-hemorrhoidectomy pain. Methods: An organized literature search was performed using electronic databases including PubMed/Medline and Google Scholar service for the articles that evaluated different methods for pain relief after excisional hemorrhoidectomy. Then, the studies were summarized in a narrative way illustrating the hypothesis and the outcomes of each study. The methods devised to reduce pain after excisional hemorrhoidectomy were classified into three main categories: technical tips; systemic and topical agents; and surgical methods. The efficacy of each method was highlighted along the level of evidence supporting it. Results: Stronger evidence (level Ia) supported LigaSure hemorrhoidectomy and the use of glyceryl trinitrate ointment to be associated with significant pain relief after excisional hemorrhoidectomy whereas the remaining methods were supported by lower level of evidence (level Ib). Conclusion: The use of LigaSure in performing excisional hemorrhoidectomy and the application of topical glyceryl trinitrate ointment contributed to remarkable relief of postoperative pain after excisional hemorrhoidectomy according to the highest level of evidence. Perhaps a multimodality strategy that combines systemic and topical agents can be the optimal method for control of pain after excisional hemorrhoidectomy, yet further prospective trials are required to draw such conclusion. Resumo: Introdução: A hemorroidectomia excisional (HE) é um dos procedimentos anorretais mais comumente realizados. Apesar dos resultados satisfatórios da hemorroidectomia excisional, a dor percebida pelos pacientes após o procedimento pode ser uma sequela angustiante. Esta revisão teve como objetivo buscar na literatura atual as evidências existentes sobre como evitar ou minimizar a gravidade da dor pós-hemorroidectomia. Métodos: Uma busca organizada da literatura foi realizada usando bancos de dados eletrônicos, incluindo PubMed/Medline e Google Scholar, para os artigos que avaliaram diferentes métodos para o alívio da dor após hemorroidectomia excisional. Em seguida, os estudos foram resumidos de forma narrativa, ilustrando a hipótese e os resultados de cada estudo. Os métodos desenvolvidos para reduzir a dor após a hemorroidectomia excisional foram classificados em três categorias principais: dicas técnicas; agentes sísticos e ticos; e métodos cirúrgicos. A eficácia de cada método foi destacada ao longo do nível de evidência que a suporta. Resultados: Evidências mais fortes (nível Ia) apoiaram a hemorroidectomia de LigaSure e o uso de pomada de trinitrato de glicerila para ser associado com alívio significativo da dor após hemorroidectomia excisional, enquanto os métodos restantes foram apoiados por menor nível de evidência (nível Ib). Conclusão: O uso de LigaSure na realização de hemorroidectomia excisional e a aplicação de pomada tópica de gliceril trinitrato contribuíram para o notável alívio da dor pós-operatória após hemorroidectomia excisional, de acordo com o maior nível de evidência. Talvez uma estratégia multimodal que combine agentes sistêmicos e tópicos possa ser o método ideal para o controle da dor após hemorroidectomia excisional, mas ainda são necessários mais estudos prospectivos para chegar a essa conclusão. Keywords: Excisional hemorrhoidectomy, Pain, Relief, Avoid, Methods, Review, Palavras-chave: Hemorroidectomia excisional, Dor, Alívio, Evitar, Métodos, Revisão

Sleeve gastrectomy (SG) has been recognised as an effective procedure for the treatment of morbid obesity and associated comorbidities; however, the shortcomings of SG, such as staple line leak, haemorrhage, vomiting, and weight regain, have also been well-reported. An underestimated adverse effect of SG is nutritional deficiency (ND). While ND is a well-known complication of malabsorptive bariatric procedures, it can still occur after restrictive operations, including SG, yet its incidence and mechanism are still unclear. In an attempt to learn about the incidence and type of ND after SG we performed an organised literature search of electronic databases searching for articles that assessed the incidence and type of ND after SG. The median incidence of iron and zinc deficiency after SG was 8.8% and 18.8%, respectively. The majority of patients already had vitamin D deficiency preoperatively, with a median of 35.5% of patients still demonstrating vitamin D deficiency postoperatively. Comparing ND before and after SG, the incidence of iron and vitamin D deficiency declined postoperatively; in contrast, there was a tangible increase in the incidence of vitamin B1, B6, B12, and calcium deficiency. Vitamin B1 and B12 deficiencies were recorded in a median of 10.0% and 11.7% of patients, respectively, and were associated with neurologic manifestations in

Abstract Background The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence. Methods The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence. Results One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI. Conclusion Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair. Trial registration Research Registry, researchregistry1891

Background. The use of prophylactic drainage after colorectal anastomoses has been long debated. This report aimed to review the current literature discussing routine drainage of colorectal anastomoses highlighting two opposite perspectives (prodrainage and antidrainage) to demonstrate the clinical utility of prophylactic drainage and its proper indications. Methods. An organized literature search was conducted querying electronic databases and Google Scholar. Articles evaluating the role of routine prophylactic drainage after colorectal anastomosis were included and divided into two categories: articles supporting the use of drains (prodrainage) and articles disputing routine drainage (antidrainage). Results. There were seven systematic reviews and/or meta-analyses, one Cochrane review, one randomized controlled trial, and six prospective or retrospective cohort studies. Six studies supported prophylactic drainage of colorectal anastomoses; the quality of these studies ranged between grade II and IV. Nine studies recommended against the use of prophylactic drainage, six studies were grade I, one was grade II, and two were grade IV. Conclusion. Since level I evidence studies including well-designed randomized trials and meta-analyses recommended against the use of pelvic drainage as a routine practice after colorectal anastomoses, we conclude no significant impact of routine drainage on the risk of anastomotic leakage after colorectal anastomoses.

Abstract In the study by Sarveazad et al. adipose tissue-derived stem cells were injected to reinforce anal sphincter repair. The authors came to the conclusion that injection of stem cells during repair surgery for fecal incontinence may cause replacement of fibrous tissue, which may be a key point in treatment of fecal incontinence. The authors emphasized in their “Discussion” section that the ability of stem cells to differentiate into muscle fibers, replacing the fibrous tissue at the site of repair, is their main action, which may not be accurate. We think that healing of repaired anal sphincter begins with granulation tissue formation, which then matures into fibrous tissue that becomes infiltrated by muscle fibers from the approximated cut ends of the sphincter, resulting in regain of sphincter muscle continuity. This is supported by many experimental studies that have evaluated local injection of stem cells during sphincteroplasty in rats and shown that the injected stem cells do not differentiate into muscle fibers but may induce healing by a strong fibrous tissue. Further studies are needed to determine the main mechanism of action of mesenchymal stems cells in augmenting anal sphincter repair.

Introduction Pneumatosis intestinalis (PI) is a broad term that describes the presence of gas in the bowel walls. The colon is affected in 36% of cases. Eosinophilic colitis (EC) is a rare form of colitis that is characterized mainly by eosinophilia in blood and affected tissues. Although eosinophilic colitis responds well to conservative treatment, yet the association of PI could be an indication of emergent surgery. Case Presentation A 48-year-old female patient with a history of recurrent attacks of abdominal pain and distention that did not respond to conservative treatment, was hospitalized and investigated thoroughly. The result of abdominal computed tomography (CT) scan indicated the presence of pneumatosis coli. Based on the findings of the CT scan, colonoscopy was done revealing hyperemic and hypertrophied mucosa at the hepatic flexure, from which multiple punch biopsies were taken for histopathological assessment. The pathological examination of these biopsies detected a diffuse active colitis of moderate severity with excess eosinophils (10 - 15/HPF), which is consistent with the diagnosis of EC. The patient improved dramatically on fluid therapy and antibiotics with complete resolution of pneumatosis coli in the follow up CT scan. However, the patient developed a severe relapse of symptoms once oral intake was resumed and this time the conservative treatment failed to improve the condition. Surgery was indicated and laparoscopic right hemicolectomy with primary anastomosis and covering ileostomy was done. The patient was free of symptoms after the operation and her postoperative course was uneventful with no complications encountered. Conclusions Eosinophilic colitis usually has a good prognosis, however its association with pneumatosis coli could reflect a serious damage to the colonic mucosa. Although eosinophilic colitis responds well to medical treatment, yet in certain cases where clinical signs are evident and pneumatosis coli is present, surgical intervention is the treatment of choice.