Combined heart and liver transplantation: an updated systematic review.

INTRODUCTION: Combined heart and liver transplantation (CHLT) is one of the most complex procedures of surgery that has been implemented in the last 35 years. The aim of our meta-analysis was to investigate the safety and efficacy of CHLT. MATERIALS: The meta-analysis was designed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews) recommendations. A literature search was conducted up to April 2020 using the MEDLINE,® SCOPUS,® ClinicalTrials.gov, Embase™, Cochrane Central Register of Controlled Trials and Google Scholar™ databases. RESULTS: Our meta-analysis included 16 studies with 860 patients. The mortality rate following CHLT was 14.1%. One and five-year survival rates were 85.3% and 71.4% while the heart and liver rejection rates were 6.1% and 9.1% respectively. The hospital stay was 25.8 days and the intensive care unit stay was 9.9 days. Pooled values were also calculated for cardiopulmonary bypass duration, units of transfused red blood cells and fresh frozen plasma, postoperative infection rate, mechanical ventilation rate and follow-up duration. CONCLUSIONS: Despite its complexity, CHLT is a safe and effective procedure for the management of lethal diseases that lead to progressive heart and/or liver failure. Nevertheless, there must be strict adherence to the indications for surgery, and future studies should compare CHLT with isolated cardiac and hepatic transplantations.

Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine.

PURPOSE: Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. METHODS: Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. RESULTS: Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation. CONCLUSION: Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

The role of LigaSure™ and Harmonic Scalpel in the preservation of recurrent laryngeal nerve during thyroidectomy.

INTRODUCTION: Transient or permanent damage to the recurrent laryngeal nerve (RLN) during thyroidectomy is of paramount importance for patient quality of life. The aim of this study is to systematically review the literature concerning the role of the most popular energy-based vessel-sealing devices (LigaSure™ (LS) and Harmonic Scalpel (HS)) in preservation of the RLN during thyroidectomy. The safety and inferiority or superiority of LS and HS compared with conventional haemostatic techniques are highlighted. METHODS: A systematic search of the literature was performed. Clinical trials, prospective and retrospective studies that significantly compared the use of LS and HS with conventional haemostasis regarding the postoperative incidence of RLN palsy were included. FINDINGS: The search resulted in 43 studies, including 17,953 patients treated using energy-based devices or conventional haemostatic methods. Concerning the incidence of RLN palsy, 40 studies showed no significant difference between the energy-based device and conventional groups, whereas two studies demonstrated a significant superiority in performance for LS and HS compared with conventional haemostasis. Only one study exhibited significant inferiority of LS and HS compared with conventional methods. No statistical relationship was observed between energy-based devices and conventional techniques regarding permanent damage to the RLN. CONCLUSION: The performance of both LS and HS shows no inferiority compared with conventional haemostatic techniques, regarding damage to the laryngeal nerve. Further well-designed studies are needed to investigate their potential benefit in preservation of the RLN.

Combined heart and liver transplantation: an updated systematic review.

INTRODUCTION: Combined heart and liver transplantation (CHLT) is one of the most complex procedures of surgery that has been implemented in the last 35 years. The aim of our meta-analysis was to investigate the safety and efficacy of CHLT. MATERIALS: The meta-analysis was designed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews) recommendations. A literature search was conducted up to April 2020 using the MEDLINE,® SCOPUS,® ClinicalTrials.gov, Embase™, Cochrane Central Register of Controlled Trials and Google Scholar™ databases. RESULTS: Our meta-analysis included 16 studies with 860 patients. The mortality rate following CHLT was 14.1%. One and five-year survival rates were 85.3% and 71.4% while the heart and liver rejection rates were 6.1% and 9.1% respectively. The hospital stay was 25.8 days and the intensive care unit stay was 9.9 days. Pooled values were also calculated for cardiopulmonary bypass duration, units of transfused red blood cells and fresh frozen plasma, postoperative infection rate, mechanical ventilation rate and follow-up duration. CONCLUSIONS: Despite its complexity, CHLT is a safe and effective procedure for the management of lethal diseases that lead to progressive heart and/or liver failure. Nevertheless, there must be strict adherence to the indications for surgery, and future studies should compare CHLT with isolated cardiac and hepatic transplantations.

Obturator hernias: a systematic review of the literature.

PURPOSE: Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate. METHODS: After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined. RESULTS: A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair. CONCLUSION: OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

Implications of the presence of the vermiform appendix inside an inguinal hernia (Amyand's hernia): a systematic review of the literature.

PURPOSE: To identify and sum all available evidence pertaining to the management of Amyand's hernia (AH). METHODS: A systematic search of the MedLine, Scopus, and Google Scholar databases was performed for studies published until January 2020. RESULTS: In total, 111 studies incorporating 161 patients were identified, 96 (86.4%) being case reports, 11 (9.9%) case series, and 4 (3.7%) retrospective patient cohorts. Mean patient age was 58.5 ± 19.6 years with 136 (83.9%) being males and 25 (16.1%) females. Furthermore, 149 (92.5%) cases were right-sided hernias while 12 (7.5%) cases were left-sided. Overall, 62.3% of patients presented emergently and 77.3% of patients' cohort were eventually diagnosed with incarcerated AH. Preoperative diagnosis of AH was established in 23.1% of patients and was achieved either by ultrasound (25%) or CT scan (75%). Operative findings consisted of normal appendix in 73 (45.4%) cases, uncomplicated appendicitis in 62 (38.5%) patients, and perforated appendix in 26 (16.1%). Regarding patients with appendicitis, mesh placement was reported for 17 (21.2%), herniorrhaphy was performed for 51 (63.7%) while 12 (15.1%) patients did not undergo hernia repair during the initial operation. Mesh utilization rates were significantly higher in patients with a normal appendix. Seven cases involved AH containing appendiceal neoplasms. Thirteen cases (8.6%) of postoperative complications were documented and a single case of postoperative death. CONCLUSION: AH is a rare type of inguinal hernia usually complicated by appendicitis. Hernia reconstruction should be tailored to each patient individually according to the extent of inguinal canal inflammation.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis.

AIM: Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD: The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS: Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION: FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

Primary adenocarcinoma of the esophagogastric junction, combined with an obscure hepatoid adenocarcinoma component, as discovered after the development of a metachronous liver metastasis.

BACKGROUND: Esophageal hepatoid adenocarcinomas (HACs) belong to alpha fetoprotein (AFP)-producing adenocarcinomas and are relatively sparse. CASE PRESENTATION: A 35-year-old man suffering from adenocarcinoma of the esophagogastric junction (EGJ), with negative preoperative studies for metastatic disease, underwent Ivor Lewis esophagectomy. The histologic examination demonstrated a poorly differentiated, IIA (T3N0M0) staged EGJ adenocarcinoma. The patient had been advised not to receive any adjuvant therapy, with the follow-up studies at six months being negative for recurrence. Eleven months postoperatively, he was diagnosed with a bulky mass in the liver's right lobe, accompanied by elevated AFP serum levels. The percutaneous biopsy revealed the presence of HAC, immunohistochemically positive for AFP. The surgical specimen was re-evaluated and was also found immunohistochemically positive for AFP, re-defining the tumor as combined adenocarcinoma and HAC of the EGJ. The patient received two sessions of transarterial chemoembolization (TACE) of the liver mass. However, following the 2nd TACE session, he developed signs of hepatic insufficiency and expired twenty days later. CONCLUSIONS: It is crucial to identify the presence of a HAC, as HAC seems to have an aggressive course, with limited therapeutic options as well as therapeutic response. HIPPOKRATIA 2020, 24(3): 138-142.

Sarcopenia does not affect postoperative complication rates in oesophageal cancer surgery: a systematic review and meta-analysis.

INTRODUCTION: The high morbidity and mortality rates after oesophagectomy indicate the need for rigorous patient selection and preoperative risk assessment. Although muscle mass depletion has been proposed as a potential prognostic factor for postoperative complications and decreased survival in gastrointestinal cancer patients, available data are conflicting. The purpose of the present meta-analysis is to determine whether sarcopenia predicts postoperative outcomes in patients undergoing oesophagectomy. METHODS: The databases MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on the effect of sarcopenia on postoperative outcomes following oesophageal cancer surgery. Outcomes included surgical complications, anastomotic leakage, respiratory complications, cardiovascular complications, postoperative infections, major complications and overall complications. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. FINDINGS: A total of eight studies involving 1488 patients diagnosed with oesophageal cancer and who underwent oesophagectomy were included in the meta-analysis. The presence of sarcopenia did not significantly increase the rate of surgical complications (odds ratio, OR, 0.86, 95% confidence interval, CI, 0.40-1.85), anastomotic leakage (OR 0.75, 95% CI 0.42-1.35), respiratory complications (OR 0.56, 95% CI 0.21-1.48), cardiovascular complications (OR 0.94, 95% CI 0.31-2.83), postoperative infection (OR 1.14, 95% CI 0.52-2.50), major complications (OR 0.81, 95% CI 0.23-2.82) or overall postoperative complications (OR 0.80, 95% 0.32-1.99). CONCLUSION: Sarcopenia does not seem to affect postoperative complication rates of patients undergoing oesophagectomy for oesophageal cancer. Future research should focus on determining whether prognosis differs according to muscle mass in this patient population.

Esophageal melanoma: a systematic review and exploratory recurrence and survival analysis.

Esophageal melanoma is a rare and poorly described malignancy. We sought to review all available data on the clinicopathological features, management options, and outcomes of patients with esophageal melanoma to guide clinicians working to treat these uncommon tumors. A systematic literature search of the PubMed, Embase, and Cochrane databases was performed. Exploratory recurrence and survival analyses were performed using previously-validated pooled Cox and logistic regression techniques for case reports and case series. Quality assessment of included studies was performed using the tools developed by the Joanna Briggs and the National Heart, Lung, and Blood Institutes. Fifty-nine studies were reviewed. A total of 93 patients with esophageal melanoma were identified. The mean patient age was 61.2 ± 10.6 years. Esophageal melanoma usually developed at the lower esophagus (48.4%). 90.3% of the patients were symptomatic at presentation, with dysphagia being the most common symptom (72%). Esophagectomy was performed in 91.4% of the patients. Postoperatively, 14 patients (15.1%) received adjuvant chemotherapy. Tumor recurrence was seen in 37 patients (39.8%). The median time to recurrence was 6 months. Disease-specific mortality was 43%. All-cause mortality was 46.1%. On multivariable Cox regression, older patient age (hazard ratio [HR] = 0.91, P = 0.008) and higher Melan-A expression (HR = 0.21; P = 0.029) were associated with a significantly lower risk of mortality. Higher S100 levels (HR = 37.4; P = 0.001) were predictive of poor survival. On logistic regression, large, ulcerated, lower esophageal tumors were significantly more likely to recur (P = 0.018, P = 0.013, and P = 0.027 respectively). Esophageal melanoma is a rare malignancy that tends to present with dysphagia. Most surgically-treated patients undergo esophagectomy. Large, ulcerated, lower esophageal lesions recur more frequently. Immunohistochemistry provides prognostic information regarding survival.

Paraduodenal hernias: a systematic review of the literature.

PURPOSE: Paraduodenal hernias (PDH), also called mesocolic hernias, account for up to 53% of all internal hernias, but they cause only 0.2-0.9% of all cases of intestinal obstruction. This is the first systematic review of all reported cases so far, investigating their clinical presentation, radiological imaging, and treatment outcomes. METHODS: After a detailed search in PubMed and Medline, using the keywords "paraduodenal hernia", 115 studies matched our criteria. A review of these reports was conducted and the full texts were examined. RESULTS: A total of 159 patients were included in our analysis, with 69.8% and 30.2% of them suffering from either a left or a right PDH, respectively. Mean age at diagnosis was 44.1 years, with a 2/1 male/female ratio. PDH were associated with non-specific symptoms and signs; abdominal pain being the most common. Computed tomography (CT) scan of the abdomen was the most frequently used diagnostic modality. Regardless of PDH localization, all patients were operated on, with approximately one-third of them undergoing a laparoscopic operation, which was associated with a significantly decreased morbidity rate as well as length of hospital stay, compared with the open repair. CONCLUSIONS: PDH are not usually associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of knowledge and clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair, seeming to be the optimum treatment strategy.

Meta-analysis of risk factors and complications associated with atrial fibrillation after oesophagectomy.

BACKGROUND: Oesophagectomy is associated with high morbidity and mortality rates. New-onset atrial fibrillation (AF) is a frequent complication following oesophagectomy. Several studies have explored whether new-onset AF is associated with adverse events after oesophagectomy. METHODS: This review was performed according to PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 25 November 2018. A meta-analysis was conducted with the use of random-effects modelling. The I2 statistic was used to assess for heterogeneity. RESULTS: In total, 53 studies including 9087 patients were eligible for analysis. The overall incidence of postoperative AF was 16·5 per cent. Coronary artery disease and hypertension were associated with AF, whereas diabetes, smoking and chronic obstructive pulmonary disease were not. Patients with AF had a significantly higher risk of overall postoperative adverse events than those without fibrillation (odds ratio (OR) 5·50, 95 per cent c.i. 3·51 to 8·30), including 30-day mortality (OR 2·49, 1·70 to 3·64), anastomotic leak (OR 2·65, 1·53 to 4·59) and pneumonia (OR 3·42, 2·39 to 4·90). CONCLUSION: Postoperative AF is frequently observed in patients undergoing oesophagectomy for cancer. It is associated with an increased risk of death and postoperative complications.

An alternative management of a Littré hernia case: food for thought.

AIM: We present a novel approach to a Littré hernia case. CASE REPORT: A 62-year old male presented at our department with a painless mass in the inguinal area and was successfully treated for an inguinal Littré hernia. A Lichtenstein tension-free mesh repair was used without performing simultaneous diverticulectomy. DISCUSSION: Resection of an asymptomatic Meckel's diverticulum remains a controversial issue. In adult population, leaving an accidentally found silent Meckel's diverticula in situ could reduce the risk of postoperative complications without increasing late complications. Mesh-based techniques provide lower recurrence rates compared to non-mesh techniques. CONCLUSIONS: Management of asymptomatic Littré hernias presents a challenge for the operating surgeon. Treatment guidelines should be developed for the optimal management of these patients.

Gastric tube volvulus following an Ivor-Lewis esophagectomy.

Gastric tube conduit is the method of choice for restoring continuity of the digestive track after a partial or total esophagectomy. Redundant gastric conduit (i.e. an elongated, floppy conduit) is a rare cause of dysphagia in patients with long survival. Gastric tube volvulus is exceedingly rare with only three cases described in the literature. We present the diagnostic and therapeutic course of a 57-year-old man who presented to our department with gastric tube volvulus 32 months after an Ivor-Lewis esophagectomy. Diagnosis was made with computed tomography and volvulus was reduced endoscopically. To the best of our knowledge, this is only the fourth case of gastric tube volvulus described in the English literature. This rare situation might be a consequence of a redundant gastric tube. Endoscopic volvulus decompression was successful in our case.

Littre's hernia: a systematic review of the literature.

PURPOSE: A hernia containing Meckel's diverticulum is called a Littre's Hernia. It's a rare entity and its diagnosis is often incidental during routine hernia repair surgery. The objective of this study is the evaluation of the current evidence on Littre's hernias regarding their clinical presentation and optimal treatment approach. METHODS: PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: August 1st, 2018) for studies reporting on Littre's hernias in adult population. RESULTS: Forty-five studies met our inclusion criteria and reported collectively on 53 patients (21 males and 32 females) presenting at health care units with a Littre's hernia. The most common sites of occurrence were femoral (39.6%) and inguinal (34%). The vast majority of cases (77.4%) concerned incarcerated hernias. All patients underwent surgical hernia repair accompanied by a diverticulectomy and 16.9% of them received mesh. Only 7.5% of patients experienced immediate postoperative complications. CONCLUSIONS: A Littre hernia is a rare complication of Meckel's diverticulum. It requires surgical attention and all medical professionals should be encouraged to report such cases to expand our experience and optimize the therapeutic approach.

Diverticulitis of the transverse colon manifesting as colocutaneous fistula.

The transverse colon is a particularly rare site for a diverticulum to develop, with only few reports of solitary diverticula described in the literature. Among the reported complications, colocutaneous fistulas appear relatively infrequently. We describe the case of an 80-year-old woman with a solitary diverticulum of the transverse colon presenting as acute diverticulitis with abscess formation in the epigastric region. A fistulous tract was found between the inflamed colon and the skin. A wedge resection of the inflamed colon together with the fistula and the solitary diverticulum was performed followed by primary suturing of the healthy colonic tissue. Despite the sufficient treatment and thorough clearance of the area, the patient died ten days later from ventilator associated pneumonia. Although rare, in patients presenting with a subcutaneous abscess in the abdominal region, there should be a high level of suspicion for active intraperitoneal inflammation derived from complicated diverticular disease given the continuously elevated prevalence of the condition in Western societies. The decision regarding proper management of this clinical state should be based on thorough clinical examination and imaging.

Targeting histone deacetylases in endometrial cancer: a paradigm-shifting therapeutic strategy?

OBJECTIVE: Endometrial cancer is increasingly prevalent in western societies and affects mainly postmenopausal women; notably incidence rates have been rising by 1.9% per year on average since 2005. Although the early-stage endometrial cancer can be effectively managed with surgery, more advanced stages of the disease require multimodality treatment with varying results. In recent years, endometrial cancer has been extensively studied at the molecular level in an attempt to develop effective therapies. Recently, a family of compounds that alter epigenetic expression, namely histone deacetylase inhibitors, have shown promise as possible therapeutic agents in endometrial cancer. The present review aims to discuss the therapeutic potential of these agents. MATERIALS AND METHODS: This literature review was performed using the MEDLINE database; the search terms histone, deacetylase, inhibitors, endometrial, targeted therapies for endometrial cancer were employed to identify relevant studies. We only reviewed English language publications and also considered studies that were not entirely focused on endometrial cancer. Ultimately, sixty-four articles published until January 2018 were incorporated into our review. RESULTS: Studies in cell cultures have demonstrated that histone deacetylase inhibitors exert their antineoplastic activity by promoting expression of p21WAF1 and p27KIP1, cyclin-dependent kinase inhibitors, that have important roles in cell cycle regulation; importantly, the transcription of specific genes (e.g., E-cadherin, PTEN) that are commonly silenced in endometrial cancer is also enhanced. In addition to these abstracts effects, novel compounds with histone deacetylase inhibitor activity (e.g., scriptaid, trichostatin, entinostat) have also demonstrated significant antineoplastic activity both in vitro and in vivo, by liming tumor growth, inducing apoptosis, inhibiting angiogenesis and potentiating the effects of chemotherapy. CONCLUSIONS: The applications of histone deacetylase inhibitors in endometrial cancer appear promising; nonetheless, additional trials are necessary to establish the therapeutic role, clinical utility, and safety of these promising compounds.