The results of this meta-analysis demonstrate that single-incision laparoscopic cholecystectomy is a safe procedure for the treatment of uncomplicated gallstone disease, with postoperative outcome similar to that of standard multiport laparoscopic cholecystectomy. Future high-powered randomized studies should be focused on elucidating subtle differences in postoperative complications, reported postoperative pain, and cosmesis following SILS cholecystectomy in more severe biliary disease.

Careful patient selection and surgeons' experience are important in the selection of technique for recurrent inguinal hernia repair.

The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35-0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54-2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6-6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62-0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64-0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.

Conclusions: T4 endothoracic sympathetic clip application is effective and safe for treatment of patients with upper limb hyperhidrosis, particularly for those with isolated palmar hyperhidrosis but also to a lesser extent for those with combined palmoaxillary hyperhidrosis.Summary: Endothoracic sympathectomy has been established as an effective and safe therapeutic option for patients with primary upper extremity hyperhidrosis. The major drawback, however, is compensatory sweating. Limited intervention at the fourth thoracic ganglion (T4) should result in lower levels of compensatory sweating in patients treated for upper limb hyperhidrosis. Preservation of inhibitory reflex mechanisms above T4 inhibits increased sweating from other body regions (Lin CC et al, Ann Chir Gynaecol 2001;90:161-6). In this study, the authors sought to evaluate long-term outcomes of endothoracic sympathetic block at T4 (EST4). Special emphasis was placed on evaluation of disease-specific quality of life (QoL) through review of a prospectively accumulated database. This was a prospective study conducted at a university hospital where patients treated with EST4 for palmar or palmoaxillary hyperhidrosis between 2001 and 2008 were evaluated. Questionnaires were developed by Keller and Milanez de Campos to evaluate disease-specific QoL. There were 374 EST4 procedures performed in 189 patients. Of 174 evaluated patients, 54 (31.0%) had palmar and 120 (69.0%) had palmoaxillary hyperhidrosis. Median follow-up was 92 months. EST4 successfully reduced hyperhidrosis in both groups (P < .001) and improved QoL (P < .001). Improvement remained stable after 5 years. However, the overall satisfaction rate did decrease secondary to the development of compensatory sweating and recurrence during follow-up. Compensatory sweating affected 41 patients (23.6%) and was severe in 11 of the 163 patients (6.7%) with 5-year follow-up. Severity of compensatory sweating did not further worsen with time, but occurrence of severe hyperhidrosis increased to 11% at the end of follow-up. Severe compensatory sweating was twice as common in patients treated for palmoaxillary sweating than those treated for palmar sweating (13.2% vs 6.1%).Comment: The most irritating side effect after upper extremity sympathectomy is compensatory sweating. In such cases, sweating is activated by stressors such as physical examination, heat, and psychologic stress. However, no patient in this study apparently considered the compensatory sweating, even when "severe" to be intolerable. Although there are other therapies for severe hyperhidrosis, such as botulinum toxin injections and axillary sweat gland aspiration, overall endoscopic sympathectomy at T4 seems to result in both favorable and durable clinical outcomes, particularly for patients with palmar hyperhidrosis, but to a lesser extent, for those with combined palmoaxillary hyperhidrosis as well.

Aortic dissection represents the most common aortic emergency, affecting 3 to 4 per 100,000 people per year and is still associated with a high mortality. Twenty percent of the patients with aortic dissection die before reaching hospital and 30% die during hospital admission. Aortic dissections may be classified in 3 ways: according to their anatomical extent (the Stanford or DeBakey systems), according to the time from onset (acute or chronic), and according to the underlying pathology (the European Society of Cardiologists' system). Advances in endovascular technology have provided new treatment options. Hybrid endovascular and conventional open surgical repair represent the mainstay of treatment for acute type A dissection. Medical management remains the gold standard for acute and uncomplicated chronic type B dissection, though endovascular surgery offers exciting potential in the management of complicated type B dissection through sealing of the intimal entry tear.

No abstract

The aim of this systematic review and pooled analysis is to determine the effect of enhanced recovery programs (ERP) on clinical outcome measures following esophagectomy. Medline, Embase, trial registries, conference proceedings, and reference lists were searched for trials comparing clinical outcome from esophagectomy followed by a conventional pathway with esophagectomy followed by an ERP. Primary outcomes were the incidence of postoperative mortality, anastomotic leak and pulmonary complications, and secondary outcomes were length of hospital stay and the incidence of 30-day readmission. Nine studies were included comprising 1240 patients, 661 patients underwent esophagectomy followed conventional pathway, and 579 patients underwent ERP. Utilization of ERP was associated with a reduction in the incidence of anastomotic leak (12.2-8.3%; pooled odds ratios = 0.61; 95% confidence interval = 0.39 to 0.96; P = 0.03) and pulmonary complications (29.1-19.6%; pooled odds ratios = 0.52; 95% confidence interval = 0.36 to 0.77; P = 0.001) and length of hospital stay, and no significant change in postoperative mortality or readmission rate. There was significant variation in the design of enhanced recovery protocols, surgical approach, and utilization of neoadjuvant therapies between the studies that are important confounding variables to be considered. This study suggests a benefit to the utilization of ERP following esophagectomy. The pathways provide a template for all medical personnel interacting with these patients in order to provide incremental changes in all aspects of clinical care that translates into global improvements seen in postoperative outcomes.

Many scoring systems exist for classification of the diabetic foot, few of which have been validated. Detailed scoring systems offer a valuable method for the comparison of data from different diabetic foot centres. Simplistic scoring systems may be used in clinical practice and the choice of scoring system should be determined by the population under study.