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.

Primary esophageal motility disorders (PEMD) including achalasia cardia are relatively rare disorders and diagnosed with relative accuracy using high-resolution manometry applying the new Chicago Classification v3.0. The role of additional investigations such endoscopy and barium swallow play a vital role in the diagnosis of achalasia, however their inclusion in diagnosing other PEMD is of no value as the esophagus is anatomically normal. Surgical treatment in the form of Heller myotomy and partial fundoplication is considered the gold standard for achalasia but there is uncertainty regarding the surgical treatment of other PEMD even when the patient experiences obstructive symptoms of dysphagia due to unpredictable outcome. It is therefore imperative that the patient selection and preoperative counseling should take the lead role in these patients before embarking on the surgical treatment. In recent days Heller myotomy has been challenged by a newer endoscopic technique of peroral endoscopic myotomy for achalasia treatment. However, the long-term results are still not available and caution is required. This review scrutinizes both the new and old literature regarding the diagnostic features, preoperative investigations, indications and patient's selection for the laparoscopic treatment of achalasia and other PEMD. It also aims to provide argument for and against various aspects of Heller myotomy in combination with antireflux procedures. It is hoped that further refinement of Chicago Classification may subgroup some of these PEMD and therefore provide clarity regarding the ones requiring definite surgical treatment for the improvement of their symptoms in long term.

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.

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.

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.

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.

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. (c) 2018 Elsevier Inc. All rights reserved.

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 multidisciplinary 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.

Aim: The analysis of possible mechanisms of repair failure is a necessary instrument and the best way to decrease the recurrence rate and improve the overall results. Avoiding historical errors and learning from the reported pitfalls and mistakes helps to standardize the relatively new laparoscopic techniques of trans-abdominal preperitoneal and total extraperitoneal. Materials and Methods: The video tapes of all primary laparoscopic repairs done by the author that led to recurrence were retrospectively analyzed and compared with findings at the second laparoscopic repair. A review of the available cases of recurrences occurring between 1994 and 2003 is the basis of this report. Summary: Adequate mesh size, porosity of mesh material, slitting of the mesh, correct and generous dissection of preperitoneal space and wrinkle-free placement of the mesh seem to be the more important factors in avoiding recurrence rather than strength of the material or strong penetrating fixation. Special attention should be paid to preperitoneal lipoma as a possible overlooked herniation or potential future pseudorecurrence despite nondislocated correctly positioned mesh. Conclusion: Laparoscopic hernia repair is a complex but very efficient method in experienced hands. To achieve the best possible results, it requires an acceptance of a longer learning curve, structured well-mentored training and high level of standardization of the operative procedure.

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.

PURPOSE:One of the most important measures of success of open inguinal herniorrhaphy is the incidence of recurrence. Reports suggest that up to 13% of all inguinal hernia repairs worldwide, irrespective of the approach, are repaired for recurrence. The reason as to why inguinal hernias recur is most likely multifactorial. The aim of this review is to evaluate the risk factors responsible for these recurrences in open suture and 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 open inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Inguinal hernia'; 'Open methods'; 'Suture repair'; 'Mesh repair', 'Recurrence', 'Causes', 'Humans'.RESULTS:The literature revealed several contributing modifiable and non-modifiable risk factors that were responsible for recurrence following open suture and mesh inguinal herniorrhaphy. These included perioperative, patient and hernia factors.CONCLUSIONS:Despite the advent of laparoscopic techniques, open inguinal herniorrhaphy remains one of the most common surgical operations. With open inguinal hernia repairs, risk factors for recurrence can be broadly classified into perioperative, patient and hernia factors. Certain patient and technical risk factors are modifiable and could reduce the recurrence rate. However, many others factors are non-modifiable. It is therefore imperative that the outcome of open inguinal herniorrhaphy must be optimised by careful planning and education for both surgeons and patients to achieve the lowest possible risk of subsequent surgery for recurrence.

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.

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.

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.

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 4 days 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. (C) 2016 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

Introduction: Laparoscopic Heller's myotomy (LHM) has become the preferred surgical method for treating achalasia. Evolving lesser invasive therapeutic endoscopic technique of peroral oesophageal myotomy (POEM) is providing an alternate technique for treating this condition with good results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. Methods: Search of a number of electronic databases for trials published in English language comparing LHM and POEM published between 2007 and 2016 was undertaken.Variables analyzed included (a) prior endoscopic treatment; (b) prior medical treatment; (c) prior Heller's myotomy; (d) operative time; (e) overall complications rate; (f) clinical response rate; (g) postoperative GERD; (h) length of hospital stay; (i) postoperative pain score and (j) long term GERD. Results: Seven comparative trials were analyzed totaling 483 (M=252, F=221) patients.Preoperative variables such as prior endoscopic treatment (OR 1.03, 95% CI 0.23 to 4.61; P=0.96); prior medical treatment (WMD 1.2, 95% CI 0.19 to 7.57, P=0.85); prior Heller's myotomy (WMD0.46, 95% CI 0.14 to 1.52, P=0.20) were comparable. Perioperative variables such as operative time was 26.28 minutes nonsignifi cantly longer for LHM compared to POEM. There was a comparable overall complication rate for the two procedures (OR 1.25, 95% CI 0.56 to 2.77; P=0.59). Postoperative variables such as post-op GERD rate (OR 1.27, 95% CI 0.70 to 2.30; P=0.44), length of the 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 to 4.1, P=0.08) were comparable for the two procedures. There was a significantly higher clinical treatment failure rate for LHM than POEM (OR 9.82, 95% CI 2.06 to 46.80; P < 0.01). Conclusion: POEM compares favorably to LHM for achalasia treatment in short-term outcomes. However, there was a significantly higher clinical treatment failure rate for LHM than POEM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1-year is unavailable in all the comparative trials and therefore making meaningful comparison with LHM is impossible. It is therefore imperative that good quality multicenter randomized controlled trials should be designed in the future with a minimum follow-up of five years to gauge the effectiveness and durability of these two procedures.