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Surgical Endoscopy May 2022Zenker's peroral endoscopic myotomy (Z-POEM) has revolutionized the therapeutic strategy for Zenker's diverticulum (ZD) with promising results. We conducted this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Zenker's peroral endoscopic myotomy (Z-POEM) has revolutionized the therapeutic strategy for Zenker's diverticulum (ZD) with promising results. We conducted this meta-analysis to estimate the safety and efficacy of Z-POEM for ZD and compare the feasibility and effectiveness of Z-POEM with that of flexible endoscopic septotomy (FES).
METHODS
A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and Cochrane Library databases to query for studies that assessed the safety and efficacy of Z-POEM for ZD. All articles published from inception to July 31, 2021 were included. The primary outcomes were the overall technical success rate, clinical success rate, incidence of adverse events, and clinical recurrence rate.
RESULTS
Eleven studies involving 357 patients undergone Z-POEM were included. Overall, the quality of included studies was above average, with five studies rated as high quality and six ranked as moderate quality. The overall pooled technical success rate for Z-POEM was 96.3% (95% confidence interval [CI] 93.6-97.9%; I = 0%). The total pooled clinical success rate for Z-POEM was 93.0% (95% CI 89.4-95.4%; I = 0%). The pooled incidence of adverse events for Z-POEM was 12.4% (95% CI 9.1-16.7%; I = 0%). The pooled clinical recurrence rate for Z-POEM was 11.2% (95% CI 7.6-16.2%; I = 0%). The clinical success for Z-POEM was significantly better than that of FES (relative risk [RR]: 1.11; CI 95% 1.03-1.18; p = 0.004, I = 0%), while there were no significant differences in technical success, adverse events, and clinical recurrence between Z-POEM and FES.
CONCLUSION
Z-POEM could be an effective and safe therapeutic modality for ZD, and even has a slightly higher clinical success rate than FES. However, comparative studies with long-term follow-up will be needed to further confirm our finding.
Topics: Digestive System Surgical Procedures; Esophagoscopy; Humans; Myotomy; Treatment Outcome; Zenker Diverticulum
PubMed: 35020054
DOI: 10.1007/s00464-022-09021-3 -
BMC Pediatrics Dec 2021While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly...
BACKGROUND
While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis METHODS: A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study.
RESULTS
Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel's diverticulum. Nine cases only out of the 52 cases with IPN died.
CONCLUSION
It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.
Topics: Enterocolitis, Necrotizing; Gestational Age; Humans; Infant, Newborn; Infant, Premature; Intussusception; Rare Diseases
PubMed: 34952564
DOI: 10.1186/s12887-021-03065-5 -
European Journal of Gastroenterology &... Dec 2021In the last decade, flexible endoscopic septotomy has been reported as a well-tolerated and effective treatment for Zenker's diverticulum. More recently, novel... (Meta-Analysis)
Meta-Analysis
In the last decade, flexible endoscopic septotomy has been reported as a well-tolerated and effective treatment for Zenker's diverticulum. More recently, novel endoscopic submucosal tunneling techniques, namely Zenker-PerOral Endoscopic Myotomy (Z-POEM) and PerOral Endoscopic Septotomy (POES) have been proposed to obtain complete muscular septum exposure and deeper myotomy. The aim of this study is to provide a systematic review with a meta-analysis of the first experiences of third space approaches for Zenker's diverticulum. Electronic databases (Medline, Scopus, EMBASE) were searched up to October 2020. Studies including patients with symptomatic Zenker's diverticulum who underwent endoscopic treatment by submucosal tunneling technique were eligible. Procedural, clinical and safety outcomes were assessed by pooling data with a random-effect model to obtain a proportion with a 95% confidence interval. Nine retrospective studies were eligible for inclusion (196 patients). Five studies were performed in the USA, two in Europe and two in Asia. Endoscopic treatment was feasible in 96.9% (I2 = 0%) of patients. The mean procedure duration was 36.4 ± 14.3 minutes. Clinical success was achieved after 93.4% (I2 = 0%) of procedures. The overall adverse events rate was 4.9% (I2 = 0%). No differences between the two approaches (Z-POEM vs POES) have been shown in terms of both efficacy and safety. Submucosal tunneling techniques appear to be feasible for symptomatic Zenker's diverticulum, with promising results in terms of efficacy and safety outcomes.
Topics: Endoscopy; Esophagoscopy; Humans; Myotomy; Retrospective Studies; Treatment Outcome; Zenker Diverticulum
PubMed: 34907984
DOI: 10.1097/MEG.0000000000002318 -
Minerva Urology and Nephrology Aug 2022Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with...
INTRODUCTION
Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with urological signs such as pneumaturia and fecaluria. Diagnostic investigations aim at confirming the presence of a fistula. Although conservative management can be chosen for selected individuals, most patients are mainly treated through surgical interventions. CVF represents a challenging condition, which records high rates of morbidity and mortality. Our systematic review aimed at achieving deeper knowledge of both indications, in addition to short- and long-term outcomes related to CVF management.
EVIDENCE ACQUISITION
We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.
EVIDENCE SYNTHESIS
The 22 included articles covered an approximately 37 years-study period (1982-2019), with a total 1365 patient population. CVF etiology was colonic diverticulitis in most cases (87.9%). Pneumaturia (50.1%), fecaluria (40.9%) and urinary tract infections (46.6%) were the most common symptoms. Abdomen computed tomography (CT) scan (80.5%), colonoscopy (74.5%) and cystoscopy (55.9%) were the most frequently performed diagnostic methods. Most CVF patients underwent surgery (97.1%) with open approach (63.3%). Almost all patients had colorectal resection with primary anastomosis with or without ostomy and 53.2% patients underwent primary repair or partial/total cystectomy. Four percent anastomotic leak, 1.8% bladder leak and 3.1% reoperations rates were identified. In an average 5-68-month follow-up, overall morbidity, overall mortality and recurrences rates recorded were 8-49%, 0-63% and 1.2%, respectively.
CONCLUSIONS
CVF mainly affects males and has diverticular origin in almost all cases. Pneumaturia, fecaluria and urinary tract infections are the most characteristic symptoms. Endoscopic tests and imaging are critical tools for diagnostic completion. Management of CVFs depends on the underlying disease. Surgical treatment represents the final approach and consists of resection and reanastomosis of offending intestinal segment, with or without bladder closure. In many cases, a single-stage surgical strategy is selected. Perioperative and long-term outcomes prove good.
Topics: Colon, Sigmoid; Colonoscopy; Diverticulitis, Colonic; Diverticulum; Humans; Intestinal Fistula; Male; Urinary Bladder Fistula
PubMed: 34791866
DOI: 10.23736/S2724-6051.21.04750-9 -
Journal of Clinical GastroenterologyThere is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula. (Meta-Analysis)
Meta-Analysis
BACKGROUND
There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula.
AIMS
This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula.
METHODS
With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals.
RESULTS
Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively.
CONCLUSION
POEM represents an effective and safe therapy for the treatment of esophageal diverticula.
Topics: Digestive System Surgical Procedures; Diverticulum, Esophageal; Esophageal Achalasia; Esophageal Sphincter, Lower; Humans; Myotomy; Natural Orifice Endoscopic Surgery; Treatment Outcome
PubMed: 34608024
DOI: 10.1097/MCG.0000000000001622 -
Journal of Pediatric Surgery Apr 2022Exomphalos with intestinal fistulation (EIF) is a rare variant of exomphalos with intestine opening to the surface of an intact sac, and may result in a diagnostic...
INTRODUCTION
Exomphalos with intestinal fistulation (EIF) is a rare variant of exomphalos with intestine opening to the surface of an intact sac, and may result in a diagnostic challenge. We report 3 new cases and conducted a systematic review of the literature, to characterize its association with the type of exomphalos and vitellointestinal duct (VI) as well as to evaluate its management and outcomes.
METHODS
A literature search from PubMed using keywords pertaining to exomphalos and fistulation was used to identify all unique cases reported between 1950 and 2020, in addition to the case series reported here, to establish the clinical presentation, histological findings, management and outcomes.
RESULTS
We found a total of 28 cases of EIF, of which 25 had been reported in 70 years from 19 reports. There was a male predominance (4-to-1 ratio). The majority presented as an exomphalos minor (n = 23, 82%) with a prolapsing patent VI duct (n = 16, 57%), most had evidence of Meckel's diverticulum (n = 25, 89%). All but one case were managed by fistula excision with or without ileal resection and anastomosis, followed by primary closure of the abdominal wall defect. All patients, except one with Trisomy 13 who received only palliative care, underwent surgery. Post-operative complications occurred in 7 patients (25%). Congenital anomalies were present in 12 (43%) and none had Beckwith-Wiedemann syndrome. Mortality occurred in 4 patients (14%) between 3 and 17 days. One EIF with exomphalos major failed early conservative treatment due to sac disintegration and sepsis, requiring staged closure, but had a good outcome.
DISCUSSION
EIF is a rare entity usually associated with exomphalos minor and vitelline duct involvement. EIF presentation is variable but primary surgery is the mainstay of treatment with generally good outcomes. Common features of EIF suggest a different embryopathogenesis to other forms of exomphalos.
Topics: Hernia, Umbilical; Humans; Intestinal Diseases; Male; Meckel Diverticulum; Postoperative Complications; Prolapse
PubMed: 34311970
DOI: 10.1016/j.jpedsurg.2021.06.016 -
Langenbeck's Archives of Surgery Feb 2022The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has...
BACKGROUND
The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment.
METHODS
A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008-2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included.
RESULTS
Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required.
CONCLUSION
Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple's procedure may be required depending on tissue friability and diverticular collar size.
Topics: Adult; Conservative Treatment; Diverticulum; Drainage; Duodenal Diseases; Humans; Intestinal Perforation
PubMed: 34164722
DOI: 10.1007/s00423-021-02238-1 -
ANZ Journal of Surgery Sep 2021Meckel's diverticulum (MD) is the most common congenital malformation in the gastrointestinal tract. Limited up-to-date evidence is available regarding MD in pregnancy....
INTRODUCTION
Meckel's diverticulum (MD) is the most common congenital malformation in the gastrointestinal tract. Limited up-to-date evidence is available regarding MD in pregnancy. We aim to review the available pertinent literature to help support clinical decision making and patient management in the future.
MATERIALS AND METHODS
The search term 'Meckel's diverticulum' was combined with 'pregnant' or 'pregnancy'. Database searches of EMBASE, Medline and PubMed were conducted. All papers published in English from 01/01/1990 to 01/01/2021 were included. Simple statistical analysis (t-test) was performed.
RESULTS
Twenty-seven cases were included. Average age = 26.9 years. Average gestation = 25.1 weeks. Occurrence: first trimester = 3.7%; second trimester = 48.1% and third trimester = 48.1%. Presenting symptoms: abdominal pain 88.9%; nausea/vomiting 59.3%; fever 18.5%; abdominal distension 18.5%; haematochezia 11.1%; constipation 11.1%; haematemesis 3.7%, diarrhoea 3.7% and asymptomatic 3.7%. Mean duration of preceding symptoms = 3.4 days. Diagnostic imaging modalities utilised: ultrasound = 40.7%; CT = 25.9%; MRI = 14.8%; abdominal X-ray = 11.1% and endoscopy = 7.4%. All cases required definite surgical management: laparotomy = 65.4%; laparoscopy = 15.4%; C-section = 19.2% and unreported = 3.8%. Main intra-operative findings: perforated MD = 40.7%; intussusception with MD as a lead point = 11.1%; bleeding MD = 11.1%, inflamed MD = 11.1%; small bowel obstruction = 11.1%; gangrenous MD = 3.7%; volvulus = 3.7% and unspecified = 7.4%. Mean length from ileocolic junction = 51.7 cm. Average length of stay was 7.1 days. T-test (p-value = 0.12) when comparing management strategy. Three maternal complications and two foetal mortalities.
CONCLUSION
MD and associated pathology are difficult to diagnose in the pregnant cohort. Current imaging demonstrates low diagnostic accuracy and a deviation away from recognised nuclear medicine investigations. Surgery appears the definitive management with both open and laparoscopic approaches utilised. Significant maternal morbidity and foetal mortality are associated with this condition.
Topics: Adult; Female; Humans; Intestinal Perforation; Intussusception; Laparoscopy; Laparotomy; Meckel Diverticulum; Pregnancy
PubMed: 34152674
DOI: 10.1111/ans.17014 -
Journal of Pediatric Urology Oct 2021Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have... (Meta-Analysis)
Meta-Analysis Review
Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade.
BACKGROUND
Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.
METHODS
A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.
RESULTS
The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.
CONCLUSIONS
Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.
Topics: Foreskin; Humans; Hypospadias; Infant; Male; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies; Surgical Flaps; Treatment Outcome; Urethra; Urologic Surgical Procedures, Male
PubMed: 34099397
DOI: 10.1016/j.jpurol.2021.05.014 -
Esophagus : Official Journal of the... Jul 2021The traditional way to tackle Zenker's diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has... (Meta-Analysis)
Meta-Analysis Review
The traditional way to tackle Zenker's diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has been found useful for managing diverticular diseases of the esophagus and has been termed DPOEM. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of D-POEM in diverticular disease of the esophagus and to compare it with FESD. We systematically searched PubMed and Embase, for studies reporting clinical success, technical success and adverse events in D-POEM alone or D-POEM comparing with FESD. We computed pooled prevalence for D-POEM alone and risk ratio for D-POEM vs FESD using random effect method with inverse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulum was conducted. Totally 19 studies including 341 patients were identified reporting on D-POEM. The pooled clinical, technical success and adverse event rates for D-POEM were 87.07%, 95.19% and 10.22%, respectively. The clinical success was significantly better than FESD while the technical success, adverse event rate, procedure time and length of hospital stay were comparable with FESD. The recurrence rate was negligible for D-POEM compared to FESD. On subgroup analysis by dividing into three groups of ZD, non-ZD and mixed, there was no difference between clinical, technical success and adverse event rate among the three groups. D-POEM is an effective and safe technique among both ZD and non-ZD patients and has better clinical success than FESD.
Topics: Diverticulum; Esophagoscopy; Esophagus; Humans; Myotomy; Treatment Outcome; Zenker Diverticulum
PubMed: 33880689
DOI: 10.1007/s10388-021-00839-9