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Objectives To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery. Methods The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle–Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated. Results Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: −1.40, P  < 0.00001), time to first defecation (mean difference: −1.21, P  = 0.02), time to first oral liquid diet (mean difference: −2.30, P  < 0.00001), time to first oral solid diet (mean difference: −2.40, P  < 0.00001) and length of hospital stay (mean difference: −3.09, −2.80, P  < 0.00001). ERAS protocols also resulted in lower risks of total complications (odds ratio: 0.50, P  < 0.00001), major complications (odds ratio: 0.60, P  = 0.0008), pulmonary complications (odds ratio: 0.38, P  = 0.0003), paralytic ileus (odds ratio: 0.53, 0.88, P  = 0.01) and surgical site infection (odds ratio: 0.39, P  = 0.0001). Both ERAS and non-ERAS protocols resulted in similar risk of 30-day mortality (risk difference: −0.00, P  = 0.94), need for re-admission (risk difference: −0.01, P  = 0.50) and need for re-operation (odds ratio: 0.83, P  = 0.50). Conclusions Although ERAS protocols are commonly used in elective settings, they are associated with favourable outcomes in emergency settings as indicated by reduced post-operative complications, accelerated recovery of bowel function and shorter post-operative hospital stay without increasing need for re-admission or re-operation. There should be an effort to incorporate ERAS protocols into emergency abdominal surgery settings.

Background Anastomotic leakage (AL) is one of the most significant complications after colorectal surgery, affecting length of stay, patient morbidity, mortality, and long-term oncological outcome. Serum C-reactive protein (CRP) level rises in infective and inflammatory states. Elevated CRP has been shown to be associated with anastomotic leak. Objective Perform a meta-analysis of current CRP data in AL after colorectal surgery. Data sources MEDLINE, EMBASE, CINAHL, CENTRAL databases Study selection Comparative studies studying serum CRP levels in adult patients with and without AL after colorectal surgery. Intervention(s) Elective and emergency open, laparoscopic or robotic colorectal excisions for cancer and benign pathology. Main outcome measures Mean serum CRP measurements between post-operative days (POD) 1 through 7 in patients with and without AL. Perform ROC analysis to determine cut-off CRP values to indicate AL. Results Twenty-three studies with 6647 patients (482 AL). Pooled mean time to diagnosis of AL was 7.70 days. AL associated with higher CRP on POD1 (mean difference (MD) 15.19, 95% CI 5.88–24.50, p  = 0.001), POD2 (MD 51.98, 05% CI 37.36–66.60, p  < 0.00001), POD3 (MD 96.92, 95% CI 67.96–125.89, p  < 0.00001), POD4 (MD 93.15, 95% CI 69.47–116.84, p  < 0.00001), POD5 (MD 112.10, 95% CI 89.74–134.45, p  < 0.00001), POD6 (MD 98.38, 95% CI 80.29–116.46, p  < 0.00001), and POD7 (MD 106.41, 95% CI 75.48–137.35, p  < 0.00001) compared with no AL. ROC analysis identified a cut-off CRP of 148 mg/l on POD3 with sensitivity and specificity of 95%. On POD4 through POD7, cut-off levels were 123 mg/l, 115 mg/l, 105 mg/l, and 96 mg/l, respectively, with sensitivity and specificity of 100%. Limitations Study heterogeneity, some characteristics unreported, no RCT Conclusions AL is associated with higher CRP levels on each post-operative day compared to no AL after colorectal surgery. The cut-off CRP values can be used to predict AL to expedite investigation and treatment.

BackgroundThe comparative evidence regarding the outcomes of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass (LRYGB) is poorly understood. We aimed to compare the outcomes of closure versus non-closure of mesenteric defects in LRYGB for morbid obesity.MethodsWe conducted a search of electronic information sources to identify all comparative studies investigating the outcomes of closure versus non-closure of mesenteric defects in patients undergoing LRYGB for morbid obesity. We used the Cochrane risk of bias tool and the ROBINS-I tool to assess the risk of bias of RCTs and observational studies, respectively. Random or fixed effects modelling was applied as appropriate.ResultsWe included 10,031 patients from six observational studies and 2609 patients from two RCTs. Analysis of observational studies showed closure defects resulted in lower risks of internal hernia (OR 0.28, 95% CI 0.15, 0.54) and reoperation for small bowel obstruction (SBO) (OR 0.30, 95% CI 0.10, 0.83); no difference was found between the two groups in terms of SBO not related to internal hernia (OR 1.19, 95% CI 0.47, 2.99), early SBO (OR 0.74, 95% CI 0.04, 14.38), anastomotic leak (OR 0.84, 95% CI 0.45, 1.57), bleeding (OR 1.08, 95% CI 0.62, 1.89), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Analysis of RCTs showed closure of defects resulted in lower risks of internal hernia (OR 0.29, 95% CI 0.19,0.45) and reoperation for SBO (OR 0.51, 95% CI 0.38, 0.69) but higher risks of SBO not related to internal hernia (OR 1.90, 95% CI 1.09, 3.34) and early SBO (OR 2.63, 95% CI 1.16, 5.96); no difference was found between the two groups in terms of anastomotic leak (OR 1.95, 95% CI 0.80, 4.72), bleeding (OR 0.67, 95% CI 0.38, 1.17), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94).ConclusionsOur results suggest that closure of mesenteric defects in LRYGB may be associated with lower risks of internal herniation and reoperation for SBO compared with non-closure of the defects (moderate certainty). The available evidence is inconclusive regarding the risks of SBO not related to internal hernia and early SBO (low certainty). More RCTs are needed to improve the robustness of the available evidence.

Objectives To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse. Methods We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures. Results We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR ( n =160) or LPSR ( n =147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P =0.009) but longer procedure time (MD: 23.93, P <0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: −1.02, P =0.50), CCCS (MD: −1.54, P =0.47), surgical site infection (OR: 1.48, P =0.71), and length of hospital stay (MD: −1.54, P =0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis. Conclusions LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

Purpose To compare outcomes of uncovered stent and covered stent in management of large bowel obstruction secondary to colorectal malignancy. Methods We conducted a search of electronic databases identifying studies comparing outcomes of uncovered and covered stents in management of large bowel obstruction secondary to colorectal malignancy. The Cochrane risk-of-bias tool and the Newcastle–Ottawa scale were used to assess the included studies. Random or fixed effects modelling were applied as appropriate to calculate pooled outcome data. Results One randomised controlled trial (RCT) and nine observational studies, enrolling 753 patients, were identified. Uncovered stent was associated with lower risks of complications (RR 0.57 95% CI 0.44–0.74, P  < 0.0001), tumour overgrowth (RR 0.29 95% CI 0.09–0.93, P  = 0.04), and stent migration (RR 0.29 95% CI 0.17–0.48, P  < 0.00001); longer duration of patency (MD 18.47 95% CI 10.46–26.48, P  < 0.00001); lower need for stent reinsertion (RR 0.38 95% CI 0.17–0.86, P  = 0.02); and higher risk of tumour ingrowth (RR 4.53 95% CI 1.92–10.69, P  = 0.0008). Rates of technical success (RR 1.02 95% CI 0.99–1.04, P  = 0.21), clinical success (RR 1.03 95% CI 0.98–1.08, P  = 0.32), perforation (RD 0.01 95% CI − 0.03–0.02, P  = 0.65), bleeding (RD 0.00 95% CI − 0.03–0.03, P  = 0.98), stool impaction (RR 0.56 95% CI 0.12–2.04, P  = 0.38) and stent obstruction (RR 2.23 95% CI 0.94–5.34, P  = 0.97) were similar. Conclusions Our results suggest that uncovered stents are superior as indicated by fewer complications, lower rates of stent migration, longer duration of patency and a reduced need for stent reinsertion. The best available evidence is mainly derived from non-randomised studies; there is a need for more RCTs.

Purpose To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery. Materials and Methods We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. Results A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 min (95% CI 102–172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5–97.5, I 2  = 0%), papillary access success was 95.3% (95% CI 92.5–97.5, I 2  = 0%), cannulation success was 95.3% (95% CI 92.5–97.5, I 2  = 0%), sphincterotomy success was 96.1% (95% CI 93.5–98.1, I 2  = 0%), and stone removal success was 95.9% (95% CI 92.4–98.4, I 2  = 0%). Conversion to open was required in 4.7% (95% CI 2.5–7.6, I 2  = 0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3–8, I 2  = 17%), cholangitis in 1.7% (95% CI 0.5–3.6, I 2  = 0%), and perforation in 3.7% (95% CI 1.8–6.3, I 2  = 0%). The length of hospital stay was 3 days (95% CI 2–4). Conclusions Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.

AimTo evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.MethodsA comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.ResultsFour RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) − 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.ConclusionsSPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

: To evaluate the safety of cholecystectomy in nonagenarians. : In compliance with the PRISMA statement standards, a systematic review including random-effects meta-analysis and meta-regression models was conducted. All studies reporting postoperative outcomes in patients aged ≥90 undergoing cholecystectomy were included and analyzed. : Six studies (1223 patients) were included. The risk of 30-day mortality was 5.4% (95% CI 3.1-7.7); 30-day morbidity occurred in 22% (95% CI 11.3-32.8). The mean length of hospital stay was 11.5 days (95% CI 8.3-14.6). Postoperative mortality was not affected by male sex (coefficient: 0.028, = 0.832), ASA status ≥ III (coefficient: 0.051, = 0.309), cholecystitis as indication for cholecystectomy (coefficient: -0.166, = 0.051), cholecystectomy in emergency setting (coefficient: -0.020, = 0.425), laparoscopic (coefficient: -0.104, = 0.09) or open approach (coefficient: 0.104, = 0.09), and conversion to open surgery (coefficient: 0.043, = 0.820). The GRADE certainty of evidence was low to moderate. : Subject to selection bias and confounding by fitness, the available evidence suggests that cholecystectomy in highly selected nonagenarians with good performance status, who have passed robust preoperative fitness assessment tests, may be safe with an acceptable risk of morbidity and mortality.

Background/Objectives: To evaluate short-term postoperative outcomes in octogenarians undergoing robotic pancreaticoduodenectomy. Methods: In compliance with the PRISMA statement standards, a systematic review and random-effects meta-analysis was conducted. All studies reporting short-term postoperative outcomes in patients aged ≥ 80 undergoing robotic pancreaticoduodenectomy were included and analyzed. Results: A total of 321 octogenarians from five studies were included. The mean operative time was 459.7 min (95% CI 398.6–520.8) and the estimated intraoperative blood loss was 216.1 mL (95% CI 147.4–284.8). Conversion to open occurred in 3.8% (95% CI 0.0–7.7). The risk of postoperative mortality was 4.5% (95% CI 1.7–7.2) and Clavien-Dindo grade ≥ III (major) complications occurred in 28.0% (95% CI 22.9–33.1). The risk of grade B or C postoperative pancreatic fistula was 10% (95% CI 6.5–13.5). The hospital stay was 14.9 days (95% CI 10.2–19.5). The risk of reoperation and readmission were 8.0% (95% CI 4.4–11.7) and 25.6% (95% CI 16.9–34.3), respectively. Compared to patients aged <80, the risk of major complications was higher (OR: 1.81, p = 0.010) and hospital stay was longer (MD: 5.19 days, p = 0.030) in octogenarians. Compared to the open approach, robotic approach was associated with longer operative time (MD: 137.08 min, p = 0.0009), less intraoperative blood loss (MD: −246.00 mL, p = 0.010), and lower major complications (OR: 0.62, p = 0.020). Conclusions: Subject to selection and confounding bias, robotic pancreaticoduodenectomy may be safe with acceptable postoperative mortality and morbidity in highly selected octogenarians with good performance status. The results of the current study can be used for hypothesis synthesis and power analysis in future comparative studies.