Meta-analysis: a critical appraisal of the methodology, benefits and drawbacks.

Meta-analysis has become an integral part of evidence-based decision-making processes and is being increasingly used in medical and non-medical disciplines. Aggregate data or summary statistics continue to be the mainstay of meta-analysis and are used by many professional societies to support clinical practice guidelines. Meta-analyses synthesize the summary statistics from independent trials by pooling them to estimate the underlying common effect size. The results represent the highest level of evidence but only if the chosen studies are of high quality and the selection criteria are fully satisfied. It is important to address the issues of defining an explicit and relevant question, exhaustively searching for the totality of evidence, meticulous and unbiased data transfer or extraction, assessment of between study heterogeneity and the use of appropriate statistical methods for estimating summary effect measures. This article reviews the methodology, benefits and drawbacks of performing a meta-analysis.

Suture Cruroplasty Versus Mesh Hiatal Herniorrhaphy for Large Hiatal Hernias (HHs): An Updated Meta-Analysis and Systematic Review of Randomized Controlled Trials.

BACKGROUND: To explore the clinical outcomes, safety and effectiveness of suture cruroplasty versus mesh repair for large hiatal hernias (HHs) by an updated meta-analysis. MATERIAL AND METHODS: Randomized controlled trials evaluating the effects of these 2 treatment modalities were searched from PubMed and other electronic databases between January 1991 and July 2018. The outcome variables analyzed included operating time, complications, recurrence of HH or wrap migration, reoperation, hospital stay and quality of life. RESULTS: Five randomized controlled trials totaling 478 patients (suture=222, mesh=256) were analyzed. For reoperation variable, the odds ratio was significantly 3.26 times higher for the suture group. For recurrence of HH, the odds ratio for the suture group was nonsignificantly 1.65 times higher compared with the mesh group. Comparable effects were noted for all other variables. CONCLUSIONS: Mesh repair seems to be superior to suture cruroplasty for large HH repair. Therefore, the routine use of mesh may be advantageous in selected cases.

Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Partial fundoplication is commonly performed in conjunction with Heller Myotomy. It is, however, controversial whether anterior Dor or posterior Toupet partial fundoplication is the antireflux procedure of choice. The aim was to perform a systematic review and meta-analysis of studies comparing these two procedures. MATERIAL AND METHODS: A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, Google scholar and current contents for English language articles comparing Dor and Toupet fundoplication following HM between 1991 and 2018 was performed. The outcome variables analyzed included operating time, length of hospital stay (LOHS), overall complication rate, quality of life (QOL), postoperative reflux, residual postoperative dysphagia, treatment failure and reoperations. The meta-analysis was prepared in accordance with the PRISMA-P statement. RESULTS: Seven studies totaling 486 patients (Dor = 245, Toupet = 241) were analyzed. LOHS was significantly shorter for Toupet repair compared to Dor procedure (WMD 0.73, 95% CI 0.47 to 0.99; P < 0.0001). Furthermore, patients after Toupet experienced significantly better QOL than those after Dor (WMD 1.68, 95% CI 0.68 to 2.73, P < 0.001). All other variables showed comparable effects for these two procedures. CONCLUSION: Our systematic review and meta-analysis revealed that Toupet fundoplication is superior to Dor in terms of LOHS and QOL following HM. For other variables such as postoperative reflux, postoperative dysphagia, complication rates and treatment failure, both Dor and Toupet fundoplication produced effective and equivalent results.

A Meta-Analysis and Systematic Review of Perioperative Outcomes of Laparoscopic-assisted Rectal Resection (LARR) Versus Open Rectal Resection (ORR) for Carcinoma.

AIMS AND OBJECTIVES: The aim was to conduct a systematic review and meta-analysis of the randomized evidence to determine the relative merits of perioperative outcomes of laparoscopic-assisted (LARR) versus open rectal resection (ORR) for proven rectal cancer. MATERIALS AND METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English-language randomized clinical trials comparing LARR and ORR. The meta-analysis was prepared in accordance with the PRISMA statement. Thirteen outcome variables were analyzed. Random effects meta-analyses were performed due to heterogeneity. RESULTS: A total of 14 randomized clinical trials that included 3843 rectal resections (LARR 2096, ORR 1747) were analyzed. The summary point estimates favored LARR for the intraoperative blood loss, commencement of oral intake, first bowel movement, and length of hospital stay. There was significantly longer duration of operating time of 38.29 minutes for the LARR group. Other outcome variables such as total complications, postoperative pain, postoperative ileus, abdominal abscesses, postoperative anastomotic leak, reintervention and postoperative mortality rates were found to have comparable outcomes for both cohorts. CONCLUSIONS: LARR was associated with significantly reduced blood loss, quicker resumption of oral intake, earlier return of gastrointestinal function, and shorter length of hospital stay at the expense of significantly longer operating time. Postoperative morbidity and mortality and analgesia requirement for both these groups were comparable. LARR seems to be a safe and effective alternative to ORR; however, it needs to be performed in established colorectal units with experienced laparoscopic surgeons.

Correction to: Causes of recurrence in laparoscopic inguinal hernia repair.

In the original publication, affiliation 3 was incorrectly published for the author 'Darius Ashrafi'. The correct affiliation should read as 'Department of Surgery, Sunshine Coast University Hospital, Birtinya, QLD, Australia.

Pharmaconutrition administration on outcomes of elective oncological surgery for gastrointestinal malignancies: is timing everything?-a review of published meta-analyses until the end of 2016.

The last 25 years have seen an increasing number of publications attesting the benefits of pharmaconutrition in the management of patients undergoing elective oncological gastrointestinal surgery. A number of randomized controlled trials and meta-analyses suggest the use of pharmaconutrition in this group of patients produces superior outcomes to standard nutritional formulations in terms of postoperative infective complications, anastomotic breakdown and length of hospital stay. The use of pharmaconutrition products, therefore, has gained increasing acceptance for use in elective gastrointestinal oncological surgical populations and been incorporated into practice guidelines. However, there remains doubts as to the robustness of such data supporting these recommendation. This is because studies reporting improved outcomes with pharmaconutrition (I) frequently compare this intervention with non-equivalent control groups; (II) do not report on the actual nutritional provision received by study participants; (III) overlook the potential impact of industry funding on research conducted and (IV) do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, a critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is urgently warranted to resolve some of the above mentioned issues. The aim of this review was to analyse meta-analyses published until the end of 2016 in this area to highlight the strengths and weakness of the present research and prioritize certain areas which will benefit from future research.

Management of oesophageal intramucosal carcinoma.

We present an interesting case of an intramucosal carcinoma (IMC) in the setting of Barrett's oesophagus in a 66-year-old woman. Her clinical course highlights the shifting paradigm in the approach to management of Barrett's oesophagus and IMC. With innovation in imaging and endoscopic treatment modalities, patients are detected earlier and managed prior to development of malignancy. The patient was treated with endoscopic modalities, and after 3 years' follow-up, she remains recurrence free.

Causes of recurrence in laparoscopic inguinal hernia repair.

PURPOSE: Recurrence after laparoscopic inguinal herniorrhaphy is poorly understood. Reports suggest that up to 13% of all inguinal herniorrhaphies worldwide, irrespective of the approach, are repaired for recurrence. We aim to review the risk factors responsible for these recurrences in laparoscopic mesh techniques. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer reviewed articles on the causes of recurrence following laparoscopic mesh inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Laparoscopic methods', 'Inguinal hernia; Mesh repair', 'Recurrence', 'Causes', 'Humans'. RESULTS: The literature revealed several contributing risk factors that were responsible for recurrence following laparoscopic mesh inguinal herniorrhaphy. These included modifiable and non-modifiable risk factors related to patient and surgical techniques. CONCLUSIONS: Recurrence can occur at any stage following inguinal hernia surgery. Patients' risk factors such as higher BMI, smoking, diabetes and postoperative surgical site infections increase the risk of recurrence and can be modified. Amongst the surgical factors, surgeon's experience, larger mesh with better tissue overlap and careful surgical techniques to reduce the incidence of seroma or hematoma help reduce the recurrence rate. Other factors including type of mesh and fixation of mesh have not shown any difference in the incidence of recurrence. It is hoped that future randomized controlled trials will address some of these issues and initiate preoperative management strategies to modify some of these risk factors to lower the risk of recurrence following laparoscopic inguinal herniorrhaphy.

Meta-analysis of histopathological outcomes of laparoscopic assisted rectal resection (LARR) vs open rectal resection (ORR) for carcinoma.

BACKGROUND: We conducted a meta-analysis of the randomized evidence to determine the relative merits of histopathological outcomes of laparoscopic assisted (LARR) versus open rectal resection (ORR) for rectal cancer. DATA SOURCES: A search of PubMed and other electronic databases comparing LARR and ORR between Jan 2000 and June 2016 was performed. Histopathological variables analyzed included; location of rectal tumors; complete and incomplete TME; positive and negative circumferential resection margins (+/-CRM); positive distal resected margins (+DRM); distance of tumor from DRM; number of lymph nodes harvested; resected specimen length; tumor size and perforated rectum. RESULTS: Fourteen RCTs totaling 3843 patients (LARR = 2096, ORR = 1747) were analyzed. Comparable effects were noted for all these histopathological variables except for the variable perforated rectum which favored ORR. CONCLUSIONS: LARR compares favorably to ORR for rectal cancer treatment. However, there is significantly higher risk of rectal perforation during LARR compared to ORR.

Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia.

AIMS AND OBJECTIVES: Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. MATERIALS AND METHODS: A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD. RESULTS: Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01). CONCLUSIONS: POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1 year are unavailable and eagerly awaited.

Weight Loss Outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Meta-Analysis and Systematic Review of Randomized Controlled Trials.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been proposed as cost-effective strategies to manage morbid obesity. The aim of this meta-analysis was to compare the postoperative weight loss outcomes reported in randomized control trials (RCTs) for LVSG versus LRYGB procedures. MATERIAL AND METHODS: RCTs comparing the weight loss outcomes following LVSG and LRYGB in adult population between January 2000 and November 2015 were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The review was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA). RESULTS: Nine unique RCTs described over 10 publications involving a total of 865 patients (LVSG, n=437; LRYGB, n=428) were analyzed. Postoperative follow-up ranged from 3 months to 5 years. Twelve-month excess weight loss (EWL) for LVSG ranged from 69.7% to 83%, and for LRYGB, ranged from 60.5% to 86.4%. A number of studies reported slow weight gain between the second and third years of postoperative follow-up ranging from 1.4% to 4.2%EWL. This trend was seen to continue to 5 years postoperatively (8% to 10%EWL) for both procedures. CONCLUSIONS: In conclusion, LRYGB and LVSG are comparable with regards to the weight loss outcomes in the short term, with LRYGB achieving slightly greater weight loss. Slow weight recidivism is observed after the first postoperative year following both procedures. Long-term reporting of outcomes obtained from well-designed studies using intention-to-treat analyses are identified as a major gap in the literature at present.

Changes in Non-Diabetic Comorbid Disease Status Following Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) Procedures: a Systematic Review of Randomized Controlled Trials.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been proposed as cost-effective strategies to manage obesity-related chronic disease. The aim of this systematic review was to study the peer review literature regarding postoperative nondiabetic comorbid disease resolution or improvement reported from randomized controlled trials (RCTs) comparing LVSG and LRYGB procedures. MATERIAL AND METHODS: RCTs comparing postoperative comorbid disease resolution such as hypertension, dyslipidemia, obstructive sleep apnea, joint and musculoskeletal conditions, gastroesophageal reflux disease, and menstrual irregularities following LVSG and LRYGB were included for analysis. The studies were selected from PubMed, Medline, EMBASE, Science Citation Index, Current Contents, and the Cochrane database and reported on at least one comorbidity resolution or improvement. The present work was undertaken according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA). The Jadad method for assessment of methodological quality was applied to the included studies. RESULTS: Six RCTs performed between 2005 and 2015 involving a total of 695 patients (LVSG n = 347, LRYGB n = 348) reported on the resolution or improvement of comorbid disease following LVSG and LRYGB procedures. Both bariatric procedures provide effective and almost comparable results in improving or resolving these comorbidities. CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative nondiabetic comorbid diseases in obese patients. While results are not conclusive at this time, LRYGB may provide superior results compared to LVSG in mediating the remission and/or improvement in some conditions such as dyslipidemia and arthritis.

Diabetes improvement and resolution following laparoscopic vertical sleeve gastrectomy (LVSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures: a systematic review of randomized controlled trials.

BACKGROUND: The prevalence of type 2 diabetes is growing in both developed and developing countries and is strongly linked with the prevalence of obesity. Bariatric surgical procedures such as laparoscopic vertical sleeve gastrectomy (LVSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are increasingly being utilized to manage related comorbid chronic conditions, including type 2 diabetes. METHODS: A systematic review of randomized controlled trials (RCTs) was undertaken using the PRISMA guidelines to investigate the postoperative impact on diabetes resolution following LVSG versus LRYGB. RESULTS: Seven RCTs involving a total of 732 patients (LVSG n = 365, LRYGB n = 367) met inclusion criteria. Significant diabetes resolution or improvement was reported with both procedures across all time points. Similarly, measures of glycemic control (HbA1C and fasting blood glucose levels) improved with both procedures, with earlier improvements noted in LRYGB that stabilized and did not differ from LVSG at 12 months postoperatively. Early improvements in measures of insulin resistance in both procedures were also noted in the studies that investigated this. CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative type 2 diabetes in obese patients during the reported 3- to 5-year follow-up periods. However, further studies are required before longer-term outcomes can be elucidated. Areas identified that need to be addressed for future studies on this topic include longer follow-up periods, standardized definitions and time point for reporting, and financial analysis of outcomes obtained between surgical procedures to better inform procedure selection.

Late Postoperative Complications in Laparoscopic Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-y Gastric Bypass (LRYGB): Meta-analysis and Systematic Review.

AIMS AND OBJECTIVES: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG), have been proposed as cost-effective strategies to manage obesity-related chronic disease. The objectives of this meta-analysis and systematic review were to analyze the "late postoperative complication rate (>30 days)" for these 2 procedures. MATERIALS AND METHODS: Randomized controlled trials (RCTs) published between 2000 and 2015 comparing the late complication rates, that is, >30 days following LVSG and LRYGB in adult population (ie, 16 y and above) were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The outcome variables analyzed included mortality rate, major and minor complications, and interventions required for their management and readmission rates. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran Q statistic and I index. The meta-analysis was prepared in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. RESULTS: Six RCTs involving a total of 685 patients (LVSG, n=345; LRYGB, n=340) reported late major complications. A nonstatistical reduction in relative odds favoring the LVSG procedure was observed [odds ratio (OR), 0.64; 95% confidence interval (CI), 0.21-1.97; P=0.4]. Four RCTs representing 408 patients (LVSG, n=208; LRYGB, n=200) reported late minor complications. A nonstatistically significant reduction of 36% in relative odds favoring the LVSG procedure was observed (OR, 0.64; 95% CI, 0.28-1.47; P=0.3). A 37% relative reduction in odds was observed in favor of the LVSG for the need for additional interventions to manage late postoperative complications that did not reach statistical significance (OR, 0.63; 95% CI, 0.19-2.05; P=0.4). No study specifically reported readmissions required for the management of late complication. CONCLUSIONS: This meta-analysis and systematic review of RCTs shows that the development of late (major and minor) complications is similar between LVSG and LRYGB procedures, 6 months to 3 years postoperatively, and they do not lead to higher readmission rate or reoperation rate for either procedure. However longer-term surveillance is required to accurately describe the patterns of late complications in these patients.

Mycobacterium Chelonae associated with rapid erosion of non-sutured laparoscopic gastric band.

INTRODUCTION: To describe a case of rapidly eroded laparoscopic placed non-sutured gastric band secondary to Mycobacterium chelonae. PRESENTATION OF CASE: A 65 year old male, who had undergone laparoscopic gastric banding two months prior for morbid obesity, presented to the clinic complaining of abdominal pain and night time fever of 4days duration. Urgent gastroscopy revealed eroded gastric band which was removed laparoscopically. DISCUSSION: M. chelonae are not uncommon in Queensland. Although the mode of acquisition of infection remains unclear, it is suspected that human disease results from environmental exposure to dirty soil and water. The patient lives in rural Queensland and uses tank water which may be contaminated with M. chelonae. CONCLUSION: It is imperative to consider environmentally acquired infection in patients with rapid erosion of non-sutured gastric band.

Carbon Dioxide Versus Air Insufflation for Elective Colonoscopy: A Meta-Analysis and Systematic Review of Randomized Controlled Trials.

AIMS AND OBJECTIVE: The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) comparing 2 methods of colonic insufflation for elective colonoscopy, that is, carbon dioxide (CO2) or air, and to evaluate their efficiency, safety, and side effects. MATERIALS AND METHODS: Prospective RCTs comparing CO2 versus air insufflation for colonic distension during colonoscopy were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1980 and October 2014. The outcome variables analyzed included procedural and immediate postprocedural pain (during, end, or within 15 min after procedure), early postprocedural pain (between 30 and 120 min), intermediate postprocedural pain (360 min) and late postprocedural pain (720 to 1140 min), cecal/ileal intubation rate, cecal/ileal intubation time, and total colonoscopy examination time. These outcomes were unanimously decided to be important as they influence the practical approach toward patient management within and outside of hospital. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran Q statistic and I2 index. The meta-analysis was prepared in accordance with PRISMA guidelines. RESULTS: Twenty-four RCTs totaling 3996 patients (CO2=2017, Air=1979) were analyzed. Statistically significant differences for the pooled effect size were observed for procedural and immediate postprocedural pain [weighted mean difference (WMD)=0.49; 95% confidence interval (CI), 0.32, 0.73; P=0.0005], early postprocedural pain between 30 and 120 minutes (WMD=0.25; 95% CI, 0.12, 0.49; P<0.0001), intermediate postprocedural pain, that is, 360 minutes after completion (WMD=0.35; 95% CI, 0.23, 0.52; P<0.0001), and late postprocedural pain between 720 and 1440 minutes (WMD=0.53; 95% CI, 0.34, 0.84; P=0.0061). Comparable effects were noted for cecal/ileal intubation rate (WMD=0.86; 95% CI, 0.61, 1.22; P=0.3975), cecal/ileal intubation time (WMD=-0.64; 95% CI, -1.38, 0.09; P=0.0860), and total examination time (WMD=-0.20; 95% CI, -0.96, 0.57; P=0.6133). CONCLUSIONS: On the basis of our meta-analysis and systematic review, we conclude that CO2 insufflation significantly reduces abdominal pain during and following the procedure lasting up to 24 hours. There is no difference in the cecal/ileal intubation rate and time and total examination time between the 2 methods. CO2 retention with CO2 insufflation during and after the colonoscopy shows inconsequential variation compared with air insufflation and has no adverse effect on patients. CO2 instead of air should be routinely utilized for colonoscopy.

Postoperative Early Major and Minor Complications in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Meta-Analysis and Systematic Review.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been proposed as cost-effective strategies to manage obesity-related chronic disease. The aim of this meta-analysis and systematic review was to compare the "early postoperative complication rate i.e. within 30-days" reported from randomized control trials (RCTs) comparing these two procedures. METHODS: RCTs comparing the early complication rates following LVSG and LRYGB between 2000 and 2015 were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The outcome variables analyzed included 30-day mortality, major and minor complications and interventions required for their management, length of hospital stay, readmission rates, operating time, and conversions from laparoscopic to open procedures. RESULTS: Six RCTs involving a total of 695 patients (LVSG n = 347, LRYGB n = 348) reported on early major complications. A statistically significant reduction in relative odds of early major complications favoring the LVSG procedure was noted (p = 0.05). Five RCTs representing 633 patients (LVSG n = 317, LRYGB n = 316) reported early minor complications. A non-statically significant reduction in relative odds of 29 % favoring the LVSG procedure was observed for early minor complications (p = 0.4). However, other outcomes directly related to complications which included reoperation rates, readmission rate, and 30-day mortality rate showed comparable effect size for both surgical procedures. CONCLUSIONS: This meta-analysis and systematic review of RCTs suggests that fewer early major and minor complications are associated with LVSG compared with LRYGB procedure. However, this does not translate into higher readmission rate, reoperation rate, or 30-day mortality for either procedure.

Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials.

OBJECTIVE: The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws. METHODS: Prospective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. RESULTS: Four RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90). CONCLUSIONS: On the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation.

Meta-Analysis of Early Endoscopic Retrograde Cholangiopancreatography (ERCP) ± Endoscopic Sphincterotomy (ES) Versus Conservative Management for Gallstone Pancreatitis (GSP).

CONTEXT: The utility of early endoscopic retrograde cholangiopancreatography (ERCP) ± endoscopic sphincterotomy (ES) in the treatment of gallstone pancreatitis (GSP) is still contentious. OBJECTIVES: The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) investigating the treatment of GSP by early ERCP ± ES versus conservative management and analyzing the patient outcomes. DATA SOURCES: A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database of Systematic Reviews identified all RCTs comparing early ERCP to conservative management in GSP published between January 1970 and January 2014. Search terms included "Endoscopic retrograde cholangiopancreatography (ERCP)"; "Endoscopic sphincterotomy"; "Gallstones"; "Bile duct stones"; "Gallstone pancreatitis"; "Biliary pancreatitis"; "Randomize/Randomised controlled trials"; "Conservative management/treatment"; "Human"; "English." STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: Only prospective RCTs comparing early intervention (ie, between 24 and 72 h) with ERCP ± ES versus conservative management in GSP were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Data extraction and critical appraisal was carried out independently by 2 authors (M.J.B. and M.A.M.) using predefined data fields. Variables analyzed included severity of pancreatitis (mild or severe), overall mortality, overall complications which included pseudocyst formation, organ failure (renal, respiratory, and cardiac), abnormal coagulation, biliary sepsis, and development of pancreatic abscess/phlegmon. The quality of RCTs was assessed using Jadad's scoring system. Random-effects model was used to calculate the outcomes of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran Q statistic and I2 index. The meta-analysis was prepared in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: Eleven RCTs consisting of 1314 patients (conservative management=662, ERCP=652) were analyzed. There was a near significant decrease in mortality for ERCP group compared with conservatively managed patients with severe pancreatitis [odds ratio (OR) 0.45; 95% confidence interval (CI), 0.19, 1.09; P=0.08]. In patients with mild pancreatitis, mortality results were comparable for both groups (OR 0.66; 95% CI, 0.02, 28.75; P=0.83). Overall complications were significantly reduced in the ERCP group in severe pancreatic patients (OR 0.32; 95% CI, 0.17, 0.61; P=0.00). In those with mild disease, a strong trend to decreased complications in the ERCP group was seen, however, this was not significant (OR 0.67; 95% CI, 0.43, 1.03; P=0.06). CONCLUSIONS: This meta-analysis demonstrates a significant decrease in complications in patients with severe GSP managed with early ERCP/ES compared with conservative management. As far as the mortality is concerned, no significant decrease was observed in mortality even in severe GSP patients treated with early ERCP/ES.