Background: Laparoscopic cholecystectomy combined with therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the reference minimally invasive treatment for common bile duct stones, but access remains limited in resource-constrained settings. We report the first completely minimally invasive management of choledocholithiasis achieved in Benin. Case Report: A 35-year-old man was referred for acute calculous cholecystitis with 3 months of recurrent right upper quadrant pain, fever, intermittent jaundice, dark urine, and pale stools. Investigation showed hyperbilirubinemia, cholestasis, modest cytolysis, and a coagulopathy corrected by parenteral vitamin K1. Ultrasonography showed multiple gallbladder calculi without a visible ductal stone. Laparoscopic cholecystectomy with transcystic drainage was performed; cholangiography through the drain on postoperative day 6 demonstrated three retained common bile duct stones. A laparoendoscopic rendezvous was planned, but the guidewire could not be advanced antegradely through the drain, and transpapillary salvage was undertaken. Guidewire-assisted cannulation, sphincterotomy, five basket passes, and balloon sweeping achieved complete clearance, confirmed by completion cholangiography. The procedure lasted 260 minutes. No adverse event occurred, and the patient remained asymptomatic at 8 years. Technical Considerations: Conservative case selection, correction of the coagulopathy before sphincterotomy, rehearsed multidisciplinary preparation, and predefined electrosurgical settings determined the safety of this inaugural procedure. Failure of the rendezvous was anticipated, and a transpapillary fallback was prepared in advance. Conclusion: Therapeutic ERCP can complete a fully minimally invasive biliary pathway in a resource-limited setting when introduced through careful case selection, appropriate training, multidisciplinary preparation, and standardized technique. The experience may inform centers developing advanced therapeutic endoscopy in similar settings.
Background: Robotic transabdominal preperitoneal inguinal hernia repair (r-TAPP) has been increasingly adopted, but whether it provides clinical advantages over conventional laparoscopic TAPP (l-TAPP) remains uncertain. This systematic review and meta-analysis aimed to provide an updated synthesis of randomized evidence comparing r-TAPP with l-TAPP. Methods: We searched PubMed/MEDLINE, Scopus, and CENTRAL from inception through August 3, 2026, without language restrictions. Randomized controlled trials (RCTs) comparing r-TAPP with l-TAPP in adults undergoing inguinal hernia repair were eligible. We performed random-effects meta-analyses using risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). We estimated between-study variance using restricted maximum likelihood and quantified heterogeneity using I 2 . We assessed risk of bias and certainty of evidence using RoB 2 and GRADE, respectively. Results: Five publications representing four independent RCTs comprising 401 patients were included. Of these, 195 patients underwent r-TAPP and 206 underwent l-TAPP. No statistically significant differences were observed in overall postoperative complications (RR: 0.89; 95% CI: 0.45–1.78; I 2 = 39.5%), conversion (RR: 1.00; 95% CI: 0.09–10.91; I 2 = 11.7%), operative time (MD: + 18.5 minutes; 95% CI: −8.4 to 45.5; I 2 = 97.7%), seroma (RR: 0.40; 95% CI: 0.08 to 2.03; I 2 = 0%), hematoma (RR: 0.65; 95% CI: 0.12–3.41; I 2 = 48.0%), or surgical site infection (RR: 0.33; 95% CI: 0.03–3.14; I 2 = 0%). Operative time showed substantial between-study heterogeneity, while estimates for postoperative complications were limited by sparse events and wide confidence intervals. Conclusions: Current evidence has not demonstrated a clear clinical advantage of r-TAPP over l-TAPP for short-term outcomes. However, the available evidence remains limited by the relatively small overall sample size, sparse events, imprecision, and substantial heterogeneity in operative time. Larger multicenter randomized trials with standardized outcome definitions and longer follow-up are needed to determine whether clinically meaningful differences exist between approaches.
Background: Endoscopic sleeve gastroplasty (ESG) is associated with a high incidence of postoperative nausea and vomiting (PONV) due to gastric volume reduction, preservation of vagal innervation, and inherent patient-related risk factors. Standard antiemetic prophylactic regimens are frequently insufficient in this population. This case series describes the clinical experience and postoperative outcomes associated with a multimodal antiemetic prophylaxis regimen. Methods: In this single-center retrospective case series, data from 20 adult patients who underwent ESG under general anesthesia were analyzed. Anesthesia maintenance was standardized using manually controlled intravenous infusions of propofol and remifentanil (TIVA), without volatile anesthetics. Multimodal antiemetic prophylaxis consisted of intravenous granisetron (3 mg), dexamethasone (8 mg), haloperidol (1 mg at induction + 1 mg before emergence), and fosaprepitant (150 mg). Postoperative analgesia was managed primarily with paracetamol and ibuprofen. The primary outcome was clinically documented PONV during the early postoperative period, including the PACU stay and the first 12 postoperative hours. Emergency department presentations for severe PONV within 5 postoperative days were assessed as a secondary outcome using institutional electronic health records. Results: The cohort comprised 20 patients (70% female, mean age 41.05 ± 11.22 years, mean BMI 38.33 ± 4.94 kg/m 2 ). Comorbidities were present in 55% of patients, and 80% were non-smokers. During the early postoperative period, no clinically documented episodes of PONV requiring rescue antiemetic treatment were identified. Conclusion: In this small retrospective case series, multimodal antiemetic prophylaxis combined with TIVA was associated with no institutionally documented early postoperative PONV presentations and emergency department presentations for severe PONV within 5 days after ESG. Prospective studies with standardized postoperative PONV assessment are needed to determine the efficacy of this approach. Given the limitations of a retrospective case series, prospective controlled trials incorporating systematic PONV severity scoring are warranted to establish optimized guidelines.
Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a scarless, minimally invasive alternative to conventional open thyroidectomy (OT). Although TOETVA has shown acceptable safety outcomes in thyroid surgery, its role in Graves’ disease remains uncertain because of the technical complexity associated with hypervascular thyroid glands. Methods: A systematic search was conducted across PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials through May 2026. Comparative studies evaluating TOETVA versus OT in adults with Graves’ disease were included. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using the I 2 statistic. Risk of bias and certainty of evidence were evaluated using ROBINS-I and GRADE. Results: Three retrospective comparative studies including 357 patients with Graves’ disease were analyzed; 141 underwent TOETVA, and 216 underwent open thyroidectomy (OT). TOETVA was associated with significantly longer operative time (MD +44.4 minutes; 95% CI: 22.7–66.2; P < .01; I 2 = 70.4%). No significant differences were observed regarding recurrent laryngeal nerve dysfunction, parathyroid dysfunction, hematoma, or surgical site infection. Mental nerve injury (2.13%) and conversion to open surgery (0.71%) were uncommon after TOETVA. Sensitivity analyses confirmed the robustness of operative time findings. Conclusion: TOETVA appears to be a safe and feasible alternative to OT for Graves’ disease, with comparable postoperative complication rates but longer operative times. Further prospective multicenter studies are needed to confirm these findings.
Introduction: Patients with obesity class IV and V benefit substantially from bariatric surgery, yet many do not complete the preoperative pathway. The contribution of system-level barriers and glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy to non-progression remains poorly understood, particularly in community settings. Methods: We conducted a single-center retrospective study of adults with obesity class IV and V evaluated for bariatric surgery (2024–2025). The primary outcome was progression to surgery. Variables included demographics, comorbidities, insurance, primary care physician (PCP) status, GLP-1 RA use, specialist consultation completion, prior authorization activity, and surgeon follow-up. Chi-square testing, stratified odds ratios, and multivariable logistic regression were performed. Results: Among 73 patients, 38 (52.1%) did not progress to surgery. Demographics and comorbidities were similar between groups. Patients who did not progress had lower PCP establishment (44.7% versus 97.1%, P < .001), fewer completed specialist consultations (28.9% versus 71.4%, P = .001), fewer nutrition visits ( P = .004), and fewer surgeon follow-up visits ( P < .001). GLP-1 RA use at initial consultation was associated with lower progression to surgery (57.9% versus 11.4%, OR 0.12, P = .008), with consistent findings across insurance types but a weaker association among patients without an established PCP. Patients who did not progress also had higher emergency department utilization and more system-related scheduling barriers (both P < .001). Conclusion: Non-progression to bariatric surgery was associated with modifiable system-level barriers, including limited PCP integration, incomplete specialist evaluation, and reduced surgical follow-up. GLP-1 RA use at presentation was also associated with non-progression, although this relationship may reflect differences in treatment pathways rather than a direct treatment effect. Structured patient navigation and integrated medical-surgical obesity care may improve pathway completion.
