Introduction

Laparoscopic cholecystectomy (LC) is one of the most performed surgeries worldwide. Biliary tract injuries are among the most feared complications after LC. The primary cause of biliary injuries during LC is the incorrect identification of the biliary tract anatomy. Near-infrared fluorescence (NIRF) imaging, following intravenous (IV) injection of indocyanine green (ICG), shows promise for simplifying the intraoperative visualization of biliary anatomy. This technique enables real-time identification of the cystic duct and common bile duct, potentially enhancing the outcomes of LC. This systematic review and meta-analysis aimed to investigate the effects of NIRF-ICG on LC outcomes.

Aims & Methods

This meta-analysis followed the Cochrane Handbook for Systematic Reviews of Interventions guidelines. We searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus until May 23^rd, 2024. We included randomized-controlled trials and retrospective studies comparing NIRF-ICG LC and conventional LC. Statistical analysis was performed using Review Manager 5.3 software.

Results

Fifteen studies with 1581 patients (41.1%) in the NIRF-ICG group and 2264 (58.9%) in the control group were included. The NIRF-ICG was associated with statistically significant reduced overall complications, bile leakage, and duct drainage (risk ratio (RR) = 0.62, 95% CI: [0.40, 0.95], P = 0.03; Fig 1), (RR = 0.34, 95% CI: [0.14, 0.83], P = 0.02; Fig 2), and (RR = 0.64, 95% CI: [0.44, 0.91]), P = 0.01; Fig 3), respectively. Common bile duct (CBD), cystic duct- CBD junction, and common hepatic duct visualization rates were better with the NIRF-ICG, (RR= 3.67, 95% CI: [2.62, 5.15], P < 0.001), (RR = 3.00, 95% CI: [2.03, 4.43], P < 0.001), and (RR = 2.87, 95% CI: [1.94, 4.25], P < 0.001), respectively. There was no significant difference in cystic duct visualization rate (RR = 1.40, 95% CI: [0.71, 2.78], P = 0.33).

Conclusion

NIRF following administration of ICG in LC offers better visualization of biliary tract anatomy and is associated with reduced overall complications, bile leakage, and bile duct drainage.

References

1. J. Van Den Bos et al., “Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy (FALCON): an international multicentre randomized controlled trial,” Surg Endosc, vol. 37, no. 6, pp. 4574–4584, Jun. 2023, doi: 10.1007/s00464-023-09935-6.
2. W. H. She et al., “Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial,” Surg Endosc, vol. 36, no. 6, pp. 4442–4451, Jun. 2022, doi: 10.1007/s00464-021-08795-2.
3. J. K. Koong, G. H. Ng, K. Ramayah, P. S. Koh, and B. K. Yoong, “Early identification of the critical view of safety in laparoscopic cholecystectomy using indocyanine green fluorescence cholangiography: A randomised controlled study,” Asian Journal of Surgery, vol. 44, no. 3, pp. 537–543, Mar. 2021, doi: 10.1016/j.asjsur.2020.11.002.

Introduction

Colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related death. Most colorectal cancers arise from benign polyps, especially dysplastic adenomas. Colonoscopy with polypectomy is the gold standard for preventing cancer by interrupting the adenoma-carcinoma sequence. This has led to the development of various techniques and devices for improved prevention and treatment. Hot snare endoscopic mucosal resection (HS-EMR), which combines submucosal injections with electrocautery, is commonly used for excising various colorectal polyps. However, it carries risks of diathermy-related complications, such as perforation, and bleeding. To address these issues, cold snare endoscopic mucosal resection (CS-EMR) has been proposed as an alternative. Concerns about residual adenoma/recurrence have been raised with CS-EMR. Therefore, we conducted this meta-analysis to compare the two techniques.

Aims & Methods

We searched electronic databases, including MEDLINE via PubMed, Scopus, Web of Science, and Cochrane, without restrictions on publication date or language. We included RCTs comparing CS-EMR and HS-EMR for colorectal polyp resection. Primary outcomes included the incidence of delayed bleeding and residual/recurrent adenoma (RRA).

Results

On Nov 5, 2024, our literature search across electronic databases retrieved a total of 1,888 records. Following a meticulous screening process, six studies met the eligibility criteria encompassing 1,449 patients and 1,947 polyps. Regarding safety, the overall effect estimates regarding delayed bleeding showed statistically significant results favoring CS-EMR group [OR 0.31, 95 % CI (0.12–0.76), P = 0.01] with no heterogeneity (P = 0.40; I² = 0 %). However, statistical superiority for CS-EMR could not be detected regarding early bleeding [OR 0.78, 95 % CI (0.31–1.97), P = 0.60]. Only two studies reported data on delayed perforation, showing a numerical difference favoring CS-EMR; however, statistical significance could not be obtained [OR 0.26, 95 % CI (0.03–2.41), P = 0.24]. Regarding efficacy, the overall effect estimates regarding complete resection and RRA did not favor either of the groups [OR 0.62, 95 % CI (0.25–1.53), P = 0.30], [OR 2.81, 95 % CI (0.43–18.47), P = 0.28] respectively.

Conclusion

Evidence obtained from this meta-analysis suggests that CS-EMR offers superior safety compared to HS-EMR for colorectal polyp resection. Current evidence remains limited due to the small number of studies included. Therefore, further high-quality randomized controlled trials with larger sample sizes are needed.

References

• Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.

• Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329(27):1977–81.

• Facciorusso A, Del Prete V, Antonino M, Buccino VR, Muscatiello N. Efficacy of endoscopic polypectomy techniques for colorectal polyps: a systematic review and network meta-analysis. Gastrointest Endosc. 2020;91(4):733–745.e9.

• Pohl H, Srivastava A, Bensen SP, Anderson P, Rothstein RI, Gordon SR, et al. Incomplete polyp resection during colonoscopy—results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144(1):74–80.e1.

• Tutticci N, Hewett DG. Cold snare polypectomy: A safe, effective technique for sessile polyps. Gastrointest Endosc Clin N Am. 2015;25(2):291–301.

• Kawamura T, Takeuchi Y, Asawa S, Yokota I, Matsuno T, Omori T, et al. A comparison of cold and hot snare polypectomy for small colorectal polyps: a randomized controlled trial. Am J Gastroenterol. 2018;113(3):403–411.

Introduction

Gastric outlet obstruction (GOO) is a severe complication of unresectable gastric and pancreatic cancers. Conventional gastrojejunostomy (CGJ) is a standard surgical intervention, but it is associated with a high incidence of delayed gastric emptying (DGE). Stomach-partitioning gastrojejunostomy (SPGJ) has emerged as an alternative to improve gastric emptying and enhance clinical outcomes.

Aims & Methods

We conducted a meta-analysis comparing SPGJ and CGJ in patients with GOO due to unresectable gastric or pancreatic cancers. Electronic databases were searched up to February 8, 2025. Outcomes included DGE, major postoperative complications, need for reintervention, short-term mortality, operation time, gastric outlet obstruction scoring system (GOOS), length of hospital stay (LOS), adherence to postoperative chemotherapy, and overall survival. For continuous outcomes, mean differences (MD) with 95% confidence intervals (CI) were calculated. For dichotomous outcomes, relative risks (RR) with 95% CI were reported. Reconstructed individual patient data (IPD) from Kaplan-Meier curves was utilized for survival analysis.

Results

A total of 11 studies comprising 456 patients were included. SPGJ was associated with significantly reduced DGE (RR = 0.24, 95% CI: 0.12–0.47) and postoperative major complications (RR = 0.26, 95% CI: 0.12–0.54) compared to CGJ. No significant differences were found in the need for reintervention (RR = 0.59, 95% CI: 0.21–1.64), short-term mortality (RR = 0.99, 95% CI: 0.42–2.33), or LOS (MD = -1.47 days, 95% CI: -3.10 to 0.16). GOOS scores were comparable between groups. Overall survival was also similar between SPGJ and CGJ (HR = 1.06, 95% CI: 0.66–1.70).

Conclusion

Our meta-analysis supports SPGJ as a superior option to CGJ for managing malignant GOO, offering significant reductions in DGE and postoperative complications, similar GOOS scores, and comparable safety regarding reintervention, short-term and long-term mortality, and LOS. High-quality RCTs are needed to confirm these findings and guide clinical practice.

References

1. T. Oida, K. Mimatsu, A. Kawasaki, H. Kano, Y. Kuboi, and S. Amano, “Modified Devine Exclusion with Vertical Stomach Reconstruction for Gastric Outlet Obstruction: A Novel Technique,” Journal of Gastrointestinal Surgery, vol. 13, no. 7, pp. 1226–1232, Jul. 2009, doi: 10.1007/s11605-009-0874-y IF: 2.2 Q2 2. W. Zhang et al., “The Validation of Deep Learning-Based Grading Model for Diabetic Retinopathy,” Front. Med., vol. 9, p. 839088, May 2022, doi: 10.3389/fmed.2022.839088 IF: 3.1 Q1 .
3. R. Yildirim, “Efficacy of stomach-partitioning on gastric emptying in patients undergoing palliative gastrojejunostomy for malign gastric outlet obstruction,” Ulus Travma Acil Cerrahi Derg, 2020, doi: 10.14744/tjtes.2020.14668 IF: 0.8 Q4 .

Introduction

Systemic sclerosis (SSc) is a rare autoimmune disease marked by multisystemic fibrotic and vascular involvement, mainly affecting the skin, lungs, and upper digestive tract. Skin involvement may serve as a marker for visceral severity, particularly regarding pulmonary and upper digestive manifestations. This study examined its correlation with these systemic complications in SSc patients.

Aims & Methods

A retrospective, descriptive, bicentric study was conducted on SSc patients followed in the internal medicine department between 2004 and 2024. Clinical evaluation included cutaneous involvement via modified Rodnan score, pulmonary assessment by clinical examination, imaging, and pulmonary function tests. Upper digestive involvement was explored through symptoms, esophagogastroduodenoscopy, and esophageal manometry performed in the gastroenterology department to assess motility and mucosal integrity. Statistical analysis (descriptive and analytical) was performed using SPSS (version 26) with the Chi-square test and a significance threshold of p <0.05.

Results

A total of 160 patients were included, mostly female (91.2%), with a median age of 50 years (range:13–81). Localized scleroderma was diagnosed in 76.2%. Skin involvement was assessed in 121 patients using the Rodnan score (mean:15.31; range:0–51), categorized as mild (0–10) in 35%, moderate (11–20) in 15%, severe (21–30) in 16.3%, and very severe (>30) in 9.4%.
Upper digestive involvement was observed in 31.4%, 14.9%, 18.2%, and 9.1% of patients with mild to very severe skin involvement, respectively. Among associated symptoms: epigastric pain was present in 8.4%, 5%, 5%, and 3.4%; gastroesophageal reflux disease (GERD) in 21.2%, 9.3%, 16.9%, and 8.5%; and dysphagia in 15.3%, 7.6%, 13.6%, and 6.8%, respectively.
Esophageal manometry was performed in 36.2%, showing lower esophageal sphincter (LES) hypotonia in 5%, 2.5%, 5%, and 3.3% of mild to very severe cases, respectively. Aperistalsis was noted in 3.3%, 1.7%, 0.8%, and 0.8%, with rare ineffective motility and hypocontractility. No significant association was found between skin severity and upper digestive involvement, either clinically (p=0.458) or manometrically (p=0.98).
Similarly, no correlation was found between skin and pulmonary involvement. Lung disease was observed in 56.3% of localized and 19.4% of diffuse forms. Among these, interstitial lung disease was present in 26.3%, 12.7%, 16.1%, and 9.3%; pulmonary fibrosis in 15.6%, 6.4%, 8.3%, and 1.8%; and restrictive syndrome in 15%, 9.3%, 13.1%, and 5.6%, across increasing skin severity (all p >0.3).
However, pulmonary involvement was noted in 60% of patients with upper digestive symptoms. Dyspnea was reported in 66.9%, crackles in 29.4%, cough in 27.5%, and chest pain in 6.3%. Radiology showed interstitial lung disease in 58.8% and pulmonary fibrosis in 28.8%. Among these, GERD was present in 46.5%, dysphagia in 36.1%, epigastric pain in 19.2%, and isolated abdominal pain in one case. Manometry revealed LES hypotonia in 13.1%, aperistalsis in 5%, and ineffective motility in 0.6%. In contrast to skin involvement, a significant association was found between pulmonary and upper digestive manifestations (p<0.01).

Conclusion

No correlation was found between the severity of cutaneous involvement and digestive disorders. However, a significant link was observed between pulmonary involvement and upper digestive symptoms, suggesting that uncontrolled acid reflux may contribute to pulmonary fibrosis in SSc patients. This highlights the need for early management and multidisciplinary monitoring.