Minimally Invasive Intermuscular Approaches Versus Conventional Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundTo date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for clinical and functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether minimally invasive approaches are superior to conventional approaches for clinical outcomes.MethodsAll studies comparing MI approaches to conventional approaches were eligible for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: ‘minimally invasive’, ‘muscle-sparing’, ‘THA’, ‘THR’, ‘hip arthroplasty’ and ‘hip replacement’. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the European Union (EU) clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation).ResultsTwenty studies were identified. There were 1,282 MI total hip arthroplasty (THAs) and 1,351 conventional THAs performed. There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (P = .959), aseptic revision (P = .894), instability (P = .894), infection (P = .669) and periprosthetic fracture (P = .940). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (P = .38). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in aseptic revision (P = .461) and all other outcomes between both groups.ConclusionIntermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.     

Single-Incision Versus Conventional Laparoscopic Appendectomy: A Meta-analysis of Randomized Controlled Trials

Background

Single-incision laparoscopic appendectomy (SILA) has gained enormous popularity worldwide. We conducted a meta-analysis to assess feasibility, safety, and benefits of SILA as compared with conventional laparoscopic appendectomy (CLA).

Methods

A literature search in MEDLINE, EMBASE, and Cochrane Library was performed to identify eligible randomized controlled trials (RCTs). Primary outcome measures were total postoperative complications, wound infection, intra-abdominal abscess, and ileus. Secondary outcome measures were operative time, length of hospital stay, pain scores, conversion rate, reoperation rate, and time to return to normal activity.

Results

Eight RCTs, totaling 1,211 patients (604 for SILA and 607 for CLA), met the inclusion criteria. The incidences of total postoperative complications, wound infection, intra-abdominal abscess, and ileus were statistically similar between the SILA and CLA groups. Compared with CLA, SILA was associated with a significantly longer operative time (weighted mean difference?=?5.28 min; 95 % confidence interval?=?3.61 to 6.94). Time to return to normal activity was shorter in the SILA group (by 0.69 days). Length of hospital stay, pain scores, conversion rate, and reoperation rate were similar between groups.

Conclusion

SILA is feasible and safe with no obvious advantages over CLA. Therefore, it may be considered as an alternative to CLA.     

Minimally Invasive or Conventional Aorto-bifemoral By-pass. A Randomised Study

INTRODUCTION: open transperitoneal aorto-bifemoral by-pass is still associated with a relatively high morbidity and mortality. To decrease this surgical stress, minimally invasive direct aortic surgery (MIDAS) was developed, utilizing a minilaparotomy and a retroperitoneal approach to the aorta. OBJECTIVES: to compare in a randomised controlled trial whether mortality and morbidity could be reduced with MIDAS. METHODS: from October 1997 to September 2000, 300 patients were randomised to either MIDAS (n=150) or conventional aorto-bifemoral by-pass surgery (n=150). RESULTS: the perioperative (30 days) mortality (2.6%), was equal in both groups. MIDAS were significantly reduced length of hospital stay (3.1 days), and pulmonary dysfunction. CONCLUSIONS: MIDAS reduced trauma and pain, which resulted in a shorter hospital stay, and a reduction in costs.     

Conventional and Laparoscopic Reversal of the Hartmann Procedure: a Review of Literature

Purpose

The aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives.

Methods

Medline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal.

Results

Thirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I–II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients’ refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%).

Conclusion

Hartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.     

微创小切口与传统切口在全髋关节置换术中应用的系统评价

目的 评价全髋关节置换术应用小切口是否优于传统长切口.方法 收集所有关于微创小切口与传统切口在全髋关节置换术中应用比较的随机对照试验(RCT),按Cochrane协作网标准逐个进行质量评价和Meta分析.结果 共纳入3篇RCT,包括339例患者.3个研究显示微创小切口组在术中失血量、总失血量、手术用时方面少于传统长切口,术中、术后并发症发生率无统计学意义,而对于术后镇痛药物用量、患肢功能恢复、术后影像学评价及远期手术效果由于各试验采用了不同的评价指标,不能进行合并分析.结论 微创小切口和传统长切口都可以用于全髋关节置换术,采用微创小切口在术中失血量、总失血量、手术用时方面少于传统长切口.在术中及术后并发症方面,两种切口的差异无统计学意义.因本研究的样本量较小,纳入的研究数量少,缺乏足够的证据,尚需更多设计严格的研究以增加证据的强度.     

Evidence to Support the Use of Minimally Invasive Esophagectomy for Esophageal Cancer: A Meta-analysis

OBJECTIVE To use meta-analysis to compare oncologic outcomes of minimally invasive esophagectomy (MIE) with open techniques (thoracoscopic and/or laparoscopic). Analysis includes the extent of lymph node (LN) clearance, number of LNs retrieved, staging, geographic variance, and mortality. DATA SOURCES A systematic review of the literature was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using MEDLINE, PubMed, EMBASE, and the Cochrane databases (1950-2012). We evaluated all comparative studies. STUDY SELECTION All eligible published studies with adequate oncologic data comparing MIE with open resection for carcinoma of the esophagus or esophagogastric junction. DATA EXTRACTION Two investigators independently selected studies for inclusion and exclusion by article abstraction and quality assessment. DATA SYNTHESIS After careful review, we included 16 case-control studies with 1212 patients undergoing esophagectomy. The median (range) number of LNs found in the MIE and open groups were 16 (5.7-33.9) and 10 (3.0-32.8), respectively, with a significant difference favoring MIE (P?=?.04). In comparing LN retrieval in Eastern vs Western studies, we found a significant difference in Western centers favoring MIE (P?<?.001). No statistical significance in pathologic staging was found between the open and MIE groups. Generally, no statistically significant difference was found between the open and MIE groups for survival within each time interval (30 days and 1, 2, 3, and 5 years), although the difference favored the MIE group. In comparing survival outcomes in Eastern vs Western centers, a nonsignificant survival advantage (across all time intervals) was found for MIE in the Eastern (P?=?.28) and Western (P?=?.44) centers. CONCLUSIONS Minimally invasive esophagectomy is a viable alternative to open techniques. Meta-analytic evidence finds equivalent oncologic outcomes to conventional open esophagectomy.     

Minimally Invasive Video-Assisted Parathyroidectomy Versus Open Minimally Invasive Parathyroidectomy for a Solitary Parathyroid Adenoma: A Prospective, Randomized, Blinded Trial

Background A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. Materials and Methods Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc^99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. Results All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 ± 18.9 vs. 49.7 ± 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 ± 6.1 vs. 32.2 ± 4.6; 26.4 ± 4.5 vs. 32.0 ± 4.0; 19.6 ± 4.9 vs. 25.4 ± 3.8; 15.5 ± 5.5 vs. 20.4 ± 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 ± 46.4 mg vs. 121.6 ± 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 ± 6.9 vs. 84.6 ± 4.7 and 90.3 ± 4.7 vs. 87.5 ± 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 ± 2.2 mm vs. 30.8 ± 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 ± 12.4% vs. 77.4 ± 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 ± 63.4 vs. 1,015 ± 61.8; P < 0.001) while the mean hospital stay was similar (28 ± 10.1 vs. 31.1 ± 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. Conclusions Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement. The paper was presented at the 41st World Congress of Surgery, 21– 25 August 2005, Durban, South Africa.     

Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis

Background

Adrenalectomy can be performed via open and various minimally invasive approaches. The aim of this systematic review was to summarize the current evidence on surgical techniques of adrenalectomy.

Methods

Systematic literature searches (MEDLINE, EMBASE, Web of Science, Cochrane Library) were conducted to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing at least two surgical procedures for adrenalectomy. Statistical analyses were performed, and meta-analyses were conducted. Furthermore, an indirect comparison of RCTs and a network meta-analysis of CCTs were carried out for each outcome.

Results

Twenty-six trials (1710 patients) were included. Postoperative complication rates did not show differences for open and minimally invasive techniques. Operation time was significantly shorter for open adrenalectomy than for the robotic approach (p < 0.001). No differences were found between laparoscopic and robotic approaches. Network meta-analysis showed open adrenalectomy to be the fastest technique. Blood loss was significantly reduced in the robotic arm compared with open and laparoscopic adrenalectomy (p = 0.01). Length of hospital stay (LOS) was significantly lower after conventional laparoscopy than open adrenalectomy in CCTs (p < 0.001). Furthermore, both retroperitoneoscopic (p < 0.001) and robotic access (p < 0.001) led to another significant reduction of LOS compared with conventional laparoscopy. This difference was not consistent in RCTs. Network meta-analysis revealed the lowest LOS after retroperitoneoscopic adrenalectomy.

Conclusion

Minimally invasive adrenalectomy is safe and should be preferred over open adrenalectomy due to shorter LOS, lower blood loss, and equivalent complication rates. The retroperitoneoscopic access features the shortest LOS and operating time. Further high-quality RCTs are warranted, especially to compare the posterior retroperitoneoscopic and the transperitoneal robotic approach.

     

Minimally Invasive Liver Resection: Robotic Versus Laparoscopic Left Lateral Sectionectomy

Background

The purpose of this study was to compare the clinical and economic outcomes of robotic versus laparoscopic left lateral sectionectomy (LLS).

Methods

A retrospective analysis was made comparing robotic (n?=?11) and laparoscopic (n?=?18) LLS performed at the University of Pittsburgh Medical Center between January 2009 and July 2011. Demographic data, operative, and postoperative outcomes were collected.

Results

Demographic and tumor characteristics of robotic and laparoscopic LLS were similar. There were also no significant differences in operative outcomes including estimated blood loss and operating room time. Patients undergoing robotic LLS had more admissions to the ICU (46 versus 6?%), increased rate of minor complications (27 versus 0?%), and longer lengths of stay (4 versus 3?days). There were no significant differences in major complication rates or 90-day mortality. The cost of robotic and laparoscopic LLS was not significantly different when only considering direct costs ($5,130 versus $4,408, p?=?0.401). However, robotic LLS costs were significantly greater when including indirect costs, which were estimated to be $1,423 per robotic case ($6,553 versus $4,408, p?=?0.021).

Discussion

Robotic LLS yields slightly inferior clinical outcomes and increased cost compared to the laparoscopic approach.     

Immunological Changes After Minimally Invasive or Conventional Esophageal Resection for Cancer: A Randomized Trial

Background

This study was performed as a substudy analysis of a randomized trial comparing conventional open esophagectomy [open surgical technique (OE)] by thoracotomy and laparotomy with minimally invasive esophagectomy [minimally invasive procedure (MIE)] by thoracoscopy and laparoscopy. This additional analysis focuses on the immunological changes and surgical stress response in these two randomized groups of a single center.

Methods

Patients with a resectable esophageal cancer were randomized to OE (n = 13) or MIE (n = 14). All patients received neoadjuvant chemoradiotherapy. The immunological response was measured by means of leukocyte counts, HLA-DR expression on monocytes, the acute-phase response by means of C-reactive protein (CRP), interleukin-6 (IL-6), and interleukin-8 (IL-8), and the stress response was measured by cortisol, growth hormone, and prolactin. All parameters were determined at baseline (preoperatively) and 24, 72, 96, and 168 h postoperatively.

Results

Significant differences between the two groups were seen in favor of the MIE group with regard to leukocyte counts, IL-8, and prolactin at 168 h (1 week) postoperatively. For HLA-DR expression, IL-6, and CRP levels, there were no significant differences between the two groups, although there was a clear rise in levels upon operation in both groups.

Conclusion

In this substudy of a randomized trial comparing minimally invasive and conventional open esophagectomies for cancer, significantly better preserved leukocyte counts and IL-8 levels were observed in the MIE group compared to the open group. Both findings can be related to fewer respiratory infections found postoperatively in the MIE group. Moreover, significant differences in the prolactin levels at 168 h after surgery imply that the stress response is better preserved in the MIE group. These findings indicate that less surgical trauma could lead to better preserved acute-phase and stress responses and fewer clinical manifestations of respiratory infections.     

Minimally Invasive Ablative Therapies for Invasive Breast Carcinomas: An Overview of Current Literature

Background Minimally invasive treatment may be an alternative to breast-conserving surgery. Methods A structured PubMed, Embase, Cochrane, and Web of Science search was performed. Endpoints studied were feasibility, completeness of ablation, timing of the sentinel node biopsy (SNB), imaging modalities, and treatment-related complications. Results A total of 24 articles were retrieved, and the level of evidence varied (2B-4). Mainly phase II studies with a treat-and-resect protocol were analyzed. Up to 100% completeness of ablation was reported for radiofrequency ablation (RFA), cryosurgery, and focused ultrasound (FUS). The oncologic results need further evaluation. Dynamic contrast enhanced MRI seems to be the best method for monitoring treatment response (77% sensitivity, 100% specificity). Ultrasound is suitable for guiding probes into the tumor. There is no consensus on the timing of the SNB. Conclusions All studies on minimally invasive ablative modalities published so far show that these techniques are feasible and safe. At this stage only T1 tumors should be ablated in a clinical trial setting; it is unclear which of the modalities is most suitable.     

Cost-Effectiveness of Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer

Background

A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer.

Methods

A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty.

Results

MIE was estimated to cost $1641 (95 % confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95 % confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Conclusions

MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.