EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias.

BACKGROUND: New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations. OBJECTIVE: To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn . CONCLUSION: An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process. GUIDELINE REGISTRATION NUMBER: PREPARE-2023CN018.

The role of artificial intelligence in the endoscopic diagnosis of esophageal cancer: a systematic review and meta-analysis.

Early detection of esophageal cancer is limited by accurate endoscopic diagnosis of subtle macroscopic lesions. Endoscopic interpretation is subject to expertise, diagnostic skill, and thus human error. Artificial intelligence (AI) in endoscopy is increasingly bridging this gap. This systematic review and meta-analysis consolidate the evidence on the use of AI in the endoscopic diagnosis of esophageal cancer. The systematic review was carried out using Pubmed, MEDLINE and Ovid EMBASE databases and articles on the role of AI in the endoscopic diagnosis of esophageal cancer management were included. A meta-analysis was also performed. Fourteen studies (1590 patients) assessed the use of AI in endoscopic diagnosis of esophageal squamous cell carcinoma-the pooled sensitivity and specificity were 91.2% (84.3-95.2%) and 80% (64.3-89.9%). Nine studies (478 patients) assessed AI capabilities of diagnosing esophageal adenocarcinoma with the pooled sensitivity and specificity of 93.1% (86.8-96.4) and 86.9% (81.7-90.7). The remaining studies formed the qualitative summary. AI technology, as an adjunct to endoscopy, can assist in accurate, early detection of esophageal malignancy. It has shown superior results to endoscopists alone in identifying early cancer and assessing depth of tumor invasion, with the added benefit of not requiring a specialized skill set. Despite promising results, the application in real-time endoscopy is limited, and further multicenter trials are required to accurately assess its use in routine practice.

Performance of radiomics-based artificial intelligence systems in the diagnosis and prediction of treatment response and survival in esophageal cancer: a systematic review and meta-analysis of diagnostic accuracy.

Radiomics can interpret radiological images with more detail and in less time compared to the human eye. Some challenges in managing esophageal cancer can be addressed by incorporating radiomics into image interpretation, treatment planning, and predicting response and survival. This systematic review and meta-analysis provides a summary of the evidence of radiomics in esophageal cancer. The systematic review was carried out using Pubmed, MEDLINE, and Ovid EMBASE databases-articles describing radiomics in esophageal cancer were included. A meta-analysis was also performed; 50 studies were included. For the assessment of treatment response using 18F-FDG PET/computed tomography (CT) scans, seven studies (443 patients) were included in the meta-analysis. The pooled sensitivity and specificity were 86.5% (81.1-90.6) and 87.1% (78.0-92.8). For the assessment of treatment response using CT scans, five studies (625 patients) were included in the meta-analysis, with a pooled sensitivity and specificity of 86.7% (81.4-90.7) and 76.1% (69.9-81.4). The remaining 37 studies formed the qualitative review, discussing radiomics in diagnosis, radiotherapy planning, and survival prediction. This review explores the wide-ranging possibilities of radiomics in esophageal cancer management. The sensitivities of 18F-FDG PET/CT scans and CT scans are comparable, but 18F-FDG PET/CT scans have improved specificity for AI-based prediction of treatment response. Models integrating clinical and radiomic features facilitate diagnosis and survival prediction. More research is required into comparing models and conducting large-scale studies to build a robust evidence base.

Research protocol for the Paraesophageal hernia symptom tool, a prospective multi-center cohort study to identify the need and threshold for surgery and assess the symptom response to surgery.

Large hiatus hernias with a significant paraesophageal component (types II-IV) have a range of insidious symptoms. Management of symptomatic hernias includes conservative treatment or surgery. Currently, there is no paraesophageal hernia disease-specific symptom questionnaire. As a result, many clinicians rely on the health-related quality of life questionnaires designed for gastro-esophageal reflux disease (GORD) to assess patients with hiatal hernias pre- and postoperatively. In view of this, a paraesophageal hernia symptom tool (POST) was designed. This POST questionnaire now requires validation and assessment of clinical utility. Twenty-one international sites will recruit patients with paraesophageal hernias to complete a series of questionnaires over a five-year period. There will be two cohorts of patients-patients with paraesophageal hernias undergoing surgery and patients managed conservatively. Patients are required to complete a validated GORD-HRQL, POST questionnaire, and satisfaction questionnaire preoperatively. Surgical cohorts will also complete questionnaires postoperatively at 4-6 weeks, 6 months, 12 months, and then annually for a total of 5 years. Conservatively managed patients will repeat questionnaires at 1 year. The first set of results will be released after 1 year with complete data published after a 5-year follow-up. The main results of the study will be patient's acceptance of the POST tool, clinical utility of the tool, assessment of the threshold for surgery, and patient symptom response to surgery. The study will validate the POST questionnaire and identify the relevance of the questionnaire in routine management of paraesophageal hernias.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis.

BACKGROUND: Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. OBJECTIVE: The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. METHODS: An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). RESULTS: Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. CONCLUSION: This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline.

BACKGROUND: Penetrating gluteal injuries (PGIs) are an increasingly common presentation to major trauma centers (MTCs) in the UK and especially in London. PGIs can be associated with mortality and significant morbidity. There is a paucity of consistent guidance on how best to investigate and manage these patients. METHODS: A retrospective cohort study was performed by interrogating prospectively collected patient records for PGI presenting to a level 1 MTC in London between 2017 and 2019. RESULTS: There were 125 presentations with PGI, accounting for 6.86% of all penetrating injuries. Of these, 95.2% (119) were male, with a median age of 21 (IQR 18-29), and 20.80% (26) were under 18. Compared with the 3 years prior to this study, the number of PGI increased by 87%. The absolute risk (AR) of injury to a significant structure was 27.20%; the most frequently injured structure was a blood vessel (17.60%), followed by the rectum (4.80%) and the urethra (1.60%). The AR by anatomic quadrant of injury was highest in the lower inner quadrant (56%) and lowest in the upper outer quadrant (14%). CT scanning had an overall sensitivity of 50% and specificity of 92.38% in identifying rectal injury. DISCUSSION: The anatomic quadrant of injury can be helpful in stratifying risk of rectal and urethral injuries when assessing a patient in the emergency department. Given the low sensitivity in identifying rectal injury on initial CT, this data supports assesing any patients considered at high risk of rectal injury with an examination under general anesthetic with or without rigid sigmoidoscopy. The pathway has created a clear tool that optimizes investigation and treatment, minimizing the likelihood of missed injury or unnecessary use of resources. It therefore represents a potential pathway other centers receiving a similar trauma burden could consider adopting. LEVEL OF EVIDENCE: 2b.

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis.

BACKGROUND: Previous clinical trials and institutional studies have demonstrated that surgery for the treatment of obesity (termed bariatric or metabolic surgery) reduces all-cause mortality and the development of obesity-related diseases such as type 2 diabetes mellitus (T2DM), hypertension, and dyslipidaemia. The current study analysed large-scale population studies to assess the association of bariatric surgery with long-term mortality and incidence of new-onset obesity-related disease at a national level. METHODS AND FINDINGS: A systematic literature search of Medline (via PubMed), Embase, and Web of Science was performed. Articles were included if they were national or regional administrative database cohort studies reporting comparative risk of long-term mortality or incident obesity-related diseases for patients who have undergone any form of bariatric surgery compared with an appropriate control group with a minimum follow-up period of 18 months. Meta-analysis of hazard ratios (HRs) was performed for mortality risk, and pooled odds ratios (PORs) were calculated for discrete variables relating to incident disease. Eighteen studies were identified as suitable for inclusion. There were 1,539,904 patients included in the analysis, with 269,818 receiving bariatric surgery and 1,270,086 control patients. Bariatric surgery was associated with a reduced rate of all-cause mortality (POR 0.62, 95% CI 0.55 to 0.69, p < 0.001) and cardiovascular mortality (POR 0.50, 95% CI 0.35 to 0.71, p < 0.001). Bariatric surgery was strongly associated with reduced incidence of T2DM (POR 0.39, 95% CI 0.18 to 0.83, p = 0.010), hypertension (POR 0.36, 95% CI 0.32 to 0.40, p < 0.001), dyslipidaemia (POR 0.33, 95% CI 0.14 to 0.80, p = 0.010), and ischemic heart disease (POR 0.46, 95% CI 0.29 to 0.73, p = 0.001). Limitations of the study include that it was not possible to account for unmeasured variables, which may not have been equally distributed between patient groups given the non-randomised design of the studies included. There was also heterogeneity between studies in the nature of the control group utilised, and potential adverse outcomes related to bariatric surgery were not specifically examined due to a lack of available data. CONCLUSIONS: This pooled analysis suggests that bariatric surgery is associated with reduced long-term all-cause mortality and incidence of obesity-related disease in patients with obesity for the whole operated population. The results suggest that broader access to bariatric surgery for people with obesity may reduce the long-term sequelae of this disease and provide population-level benefits.

Laparoscopic magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: systematic review and pooled analysis.

Magnetic sphincter augmentation (MSA) has been proposed as a less invasive, more appealing alternative intervention to fundoplication for the treatment of gastroesophageal reflux disease (GERD). The aim of this study was to evaluate clinical outcomes following MSA for GERD control in comparison with laparoscopic fundoplication. A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for single-arm cohort studies or comparative studies (with fundoplication) evaluating the use of MSA. A random-effects meta-analysis for postoperative proton pump inhibitor (PPI) use, GERD-health-related quality of life (GERD-HRQOL), gas bloating, ability to belch, dysphagia, and reoperation was performed. The systematic review identified 6 comparative studies of MSA versus fundoplication and 13 single-cohort studies. Following MSA, only 13.2% required postoperative PPI therapy, 7.8% dilatation, 3.3% device removal or reoperation, and esophageal erosion was seen in 0.3%. There was no significant difference between the groups in requirement for postoperative PPI therapy (pooled odds ratio, POR = 1.08; 95%CI 0.40-2.95), GERD-HRQOL score (weighted mean difference, WMD = 0.34; 95%CI -0.70-1.37), dysphagia (POR = 0.94; 95%CI 0.57-1.55), and reoperation (POR = 1.23; 95%CI 0.26-5.8). However, when compared to fundoplication MSA was associated with significantly less gas bloating (POR = 0.34; 95%CI 0.16-0.71) and a greater ability to belch (POR = 12.34; 95%CI 6.43-23.7). In conclusion, magnetic sphincter augmentation achieves good GERD symptomatic control similar to that of fundoplication, with the benefit of less gas bloating. The safety of MSA also appears acceptable with only 3.3% of patients requiring device removal. There is an urgent need for randomized data directly comparing fundoplication with MSA for the treatment of GERD to truly evaluate the efficacy of this treatment approach.

Tension haemothorax from a bleeding branch of the renal artery following isolated penetrating thoracic trauma: a rare presentation.

A 27-year-old man presented to a major trauma centre with two posterolateral thoracic stab injuries over the right scapula and thoracoabdominal junction. He was tachycardic and hypotensive with a chest X-ray revealing a large right-sided tension haemothorax, requiring insertion of two intercostal chest drains. A subsequent CT scan demonstrated a grade 4 right kidney laceration with active back bleeding from a renal artery branch, through a right diaphragmatic defect, into the pleural cavity. Embolisation of the feeding renal vessel controlled the bleeding and avoided the need for a nephrectomy. The patient required subsequent video-assisted thoracoscopic evacuation of the haemothorax and diaphragmatic repair, confirming that there was no associated lung or major vessel injury. A ureteric stent was ultimately inserted to manage a persistent urinary leak. This case highlights a rare cause for a common traumatic presentation and the need for a multidisciplinary approach in effective management of complex, multiorgan trauma.