Endoscopic transgastric fenestration versus percutaneous drainage for management of(peri)pancreatic fluid collections adjacent to gastric wall(with video)

BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic stent implantation are common.AIM To introduce a novel endoscopic therapy named endoscopic transgastric fenestration(ETGF),which involves resection of tissue by endoscopic accessory between gastric and PFCs without stent implantation,and to evaluate its efficacy and safety compared with PCD for the management of PFCs adjacent to the gastric wall.METHODS Patients diagnosed with PFCs adjacent to the gastric wall and who subsequently received ETGF or PCD were restrospectively enrolled.Indications for intervention were consistent with related guidelines.We analyzed patients baseline characteristics,technical and clinical success rate,recurrence and reintervention rate,procedure-related complications and adverse events.RESULTS Seventy-two eligible patients were retrospectively identified(ETGF=34,PCD=38)from October 2017 to May 2021.Patients in the ETGF group had a significantly higher clinical success rate than those in the PCD group(97.1 vs 76.3%,P=0.01).There were no statistically significant differences regarding recurrence,reintervention and incidence of complication between the two groups.While long-term catheter drainage was very common in the PCD group.CONCLUSION Compared with PCD,ETGF has a higher clinical success rate in the management of PFCs adjacent to the gastric wall.ETGF is an alternative effective strategy for the treatment of PFCs adjacent to the gastric wall.

Laparoscopic fenestration vs open fenestration in patients with congenital hepatic cysts: A meta-analysis

AIM: To determine whether the outcomes of laparoscopic fenestration (LF) were superior to open fenestration (OF) for congenital liver cysts.METHODS: Comparative studies published between January 1991 and May 2010 on Medline (Ovid),Emsco,PubMed,Science Direct;Cochrane Reviews;CNKI;Chinese Biomedical Database,VIP and other electronic databases were searched.Randomized controlled trials (RCTs) and retrospective case-control studies on the management of congenital hepatic cysts were collected according to the pre-determined eligibility criteria to establish a literature database.Retrieval was ended in May 2010.Meta-analysis was performed using RevMan 5.0 software (Cochrane library).RESULTS: Nine retrospective case-control studies involving 657 patients,comparing LF with OF were included for the final pooled analysis.The meta-analysis results showed less operative time [mean difference (MD): -28.76,95% CI: -31.03 to 26.49,P < 0.00001];shorter hospital stay (MD: -3.35,95% CI: -4.46 to -2.24,P < 0.00001);less intraoperative blood loss (MD: -40.18,95% CI: -52.54 to -27.82,P < 0.00001);earlier return to regular diet (MD: -29.19,95% CI: -30.65 to -27.72,P < 0.00001) and activities after operation (MD: -21.85,95% CI: -31.18 to -12.51,P < 0.0001) in LF group;there was no significant difference between the two groups in postoperative complications (odds ratio: 0.99,95% CI: 0.41 to 2.38,P = 0.98) and cysts recurrence rates.CONCLUSION: The short-term outcomes of LF for patients with congenital hepatic cysts were superior to open approach,but its long-term outcomes should be verified by further RCTs and extended follow-up.

Long-term results of laparoscopic fenestration for patients with congenital liver cysts

BACKGROUND: The feasibility and immediate outcome of laparoscopic fenestration for patients with congenital liver cysts have been generally recognized. The aim of the present study was to assess the long-term results after laparoscopic fenestration. METHODS: A retrospective study was performed on 44 patients with congenital liver cysts who had undergone laparoscopic fenestration between June 1998 and December 2004. Among them, 30 were women and 14 men, aged 57 years on average (range 18-76 years). While 14 patients had solitary cysts, 20 had multiple cysts, and 10 had polycystic liver disease. The results of laparoscopic fenestration, including mortality, morbidity, mean postoperative hospital stay, and recurrences of cysts were evaluated. RESULTS: There was no perioperative death and the morbidity rate was 11% (5/44). All complications were treated conservatively. The mean postoperative hospital stay was 4 days. A mean follow-up of 57 months showed that the rates of cyst recurrence and symptom recurrence were 9% and 4.5%, respectively. CONCLUSION: Laparoscopic fenestration as a feasible and safe treatment procedure for patients with congenital liver cysts can yield very good long-term results.

Cataract surgery in aged patients:phacoemul-sification or small-incision extracapsular cataract surgery

AIM: To evaluate the effects and safety of phacoemulsification (Phaco) or small-incision extracapsular cataract surgery (SICS) and intraocular lens (IOL) implantation for aged patients. METHODS: Totally 137 aged patients (149 eyes) underwent cataract operation in the case of stable systemic condition, the blood pressure less than 160/95mmHg, blood glucose less than 8mmol/L, and under the help of electrocardiogram surveillance by anesthesiologists during the operation. 106 aged patients (114 eyes) underwent Phaco while 31 aged patients (35 eyes) underwent SICS. The postoperative visual acuity, corneal endothelial cell loss, surgery time and major complications were observed and analyzed retrospectively. RESULTS: The best-corrected visual acuity (BCVA) of >= 0.6 was achieved in 135 eyes (92.6%) at 1 month postoperatively (chi(2)=259.730, P<0.001). For aged patients, both Phaco and SICS could significantly improve visual acuity with no significant difference (chi(2)=4.535, P > 0.05). Postoperative corneal endothelial cell loss was 18.6%, in PHACO group, the rate was 18.5%; in SICS group, the rate was 19.0%, the difference of which was no significant (chi(2)=0.102, P>0.05). The surgery time was different in two groups. No severe complications occurred. CONCLUSION: Both Phaco and SICS combined with IOL implantation for aged patients are effective and safe. Before surgery, detailed physical examination should be performed. When the systemic condition is stable, cataract surgery for aged patients is safe.

Treatment of polycystic liver disease with resection-fenestration and a new classification

AIM: To evaluate outcomes in patients with autosomal dominant polycyst liver disease (APLD) treated by combined hepatic resection and fenestration. A new classification was recommended to presume postoperative complications and long outcome of patients. METHODS: Twenty-one patients with APLD were treated by a combined hepatic resection and fenestration technique. All patients were reviewed retrospectively, and clinical symptoms, performance status and morbidity were recorded. A new classifi cation of APLD is recommended here. RESULTS: All patients were discharged when free of symptoms. The mean follow-up time was 55.7 mo and three patients had a recurrence of symptoms at 81, 68 and 43 mo after operation, respectively. The overall morbidity rate was 76.2%. Two patients with Type B-Ⅱ and Type B-Ⅰ developed biliary leakage. Four patients had severe ascites, including three with Type B-Ⅲ and one with Type B-Ⅱ, Nine patients had pleural effusion, including one with Type A-Ⅰ; one with Type B-Ⅰ; fi ve with Type B-Ⅱ; one with Type A-Ⅲ and one with Type B-Ⅲ. Three patients with Type B had recurrence of symptoms, while none with Type A had severe complications. CONCLUSION: Combined hepatic resection and fenestration is an acceptable procedure for treatment of APLD. According to our classifi cation, postoperative complications and long outcome can be predicted before surgery.

Small-incision lenticule extraction versus femtosecond lenticule extraction for myopic:a systematic review and Meta-analysis

AIM： To examine differences in efficacy, accuracy, safety, aberrations and corneal biomechanical between Small incision lenticule extraction （SMILE） and femtosecond lenticule extraction （FLEx） for myopia. METHODS： Comprehensive studies were conducted on the PubMed, MEDLINE, EMBASE, and Cochrane Controlled Trials Register before 31 July, 2015. Meta-analyses were performed on the primary outcomes [loss of ≥2 lines of corrected distance visual acuity （CDVA）, uncorrected distance visual acuity （UDVA） ≥20/20, spherical equivalent （SE） within ±0.50 diopters （D）, final refractive SE], secondary outcomes were high-order aberrations （HOAs） and corneal biomechanical [central corneal thickness （CCT）, corneal hysteresis （CH） and corneal resistance factor （CRF）]. RESULTS： Seven trials describing a total of 320 eyes with myopia were included in this Meta-analysis. No significant differences were found in the efficacy [UDVA weighted mean difference （WMD） -0.01; 95%CI： -0.04 to 0.01; P=0.37, UDVA ≥20/20, OR 1.49; 95%CI： 0.78 to 2.86; P=0.23], accuracy （SE WMD -0.03; 95%CI： -0.12 to 0.07; P=0.58 , SE within ±0.5 D OR 1.25; 95%CI： 0.34 to 4.65; P=0.74）, HOAs （WMD -0.04; 95%CI： -0.09 to 0.01; P=0.14） and CCT WMD 1.83; 95%CI： -7.07 to 10.72; P=0.69, CH WMD -0.01; 95%CI： -0.42 to 0.40; P=0.97, CRF WMD 0.17; 95%CI： -0.33 to 0.67; P=0.50） in the last fellow-up. But for safety, FLEx may achieve fewer CDVA lost two or more two lines （OR 11.11; 95%CI： 1.27 to 96.86; P=0.03） than SMILE, however CDVA （WMD 0.00; 95%CI： -0.03 to 0.02; P=0.77） is similar. CONCLUSION： SMILE and FLEx are comparable in terms of both efficacy, accuracy, aberrations and corneal biomechanical measures in the follow-up,but FLEx seems to be better in safety measures. The results should be interpreted cautiously since relevant evidence is still limited, although it is accumulating. Further large-scale, well-designed randomized controlled trials are urgently needed.

Laparoscopic fenestration of multiple giant biliary mucinous cystadenomas of the liver

Biliary cystadenomas of the liver are rare, cystic neoplasms of the biliary ductal system usually occur in middle aged women. We report a case of synchronous multiple huge biliary mucinous cystadenomas with unique features. This is, according to our knowledge, the first report in the literature about three synchronously occurring hepatobiliary cystadenomas. Cystadenomas have a strong tendency to recur, particularly following incomplete excision, and a potential of malignant transformation. A therapeutic re-evaluation may be necessary when the diagnosis of hepatobiliary cystadenoma is made after the operation and an open liver resection should be considered.

Cap morphology after small-incision lenticule extraction and its effects on intraocular scattering

AIM： To investigate cap morphology after small-incision lenticule extraction （SMILE） and its effects on intraocular scattering. METHODS： Sixty-five eyes of 33 patients undergoing SMILE were enrolled. In addition to regular evaluation, Fourier-domain optical coherence tomography was used to investigate cap thickness at ld, lwk, 1 and 3mo postoperatively. The optical quality including modulation transfer function cutoff frequency, Strehl ratio, Optical Quality Analysis System （OQAS） values, and objective scattering index （OSI）, were evaluated using OQASTM. RESULTS： Cap thickness decreased from ld to lwk （P〈0.001）, but remained higher than intended thickness of 120 μm after 3mo （P〈0.001）. Cap thickness in central area was thinner than that of in the paracentral and peripheral areas （P〈0.0001）. Total number of microdistortions decreased from ld to 3mo （P〈0.0001）. Pearson analysis revealed a weak correlation between OSI and standard deviation of cap thickness at ld and lmo, as well as between range of cap thickness and OSI at 1mo. No correlation was found between microdistortion and OSI, but a negative correlation existed between microdistortion and range at ld and lmoafter surgery. CONCLUSION： The corneal cap tends to be more accurate and regular with time lapse. Better cap morphology tends to contribute less intraocular scattering in the eyes undergoing SMILE.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated problems. We explored endoscopic gastric fenestration(EGF) as an innovative alternative intervention.AIM To assess the feasibility, efficacy and safety of EGF for WON.METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound(EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min(EUS assessment, 32.3 min;initial fenestration, 28.8 min;expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent(LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Comparison of clinical outcome of small-incision lenticule intrastromal keratoplasty and FS-LASIK for correction of moderate and high hyperopia

AIM:To compare the clinical outcome of small-incision lenticule intrastromal keratoplasty(s LIKE)and femtosecond laser-assisted in situ keratomileusis(FS-LASIK)for correction of moderate and high hyperopia.METHODS:A case-controlled clinical study was performed.Twenty right eyes of 20 moderate and high hyperopia patients underwent s LIKE(s LIKE group)and 22 right eyes of 22 moderate and high hyperopia patients underwent FS-LASIK(FS-LASIK group)were enrolled in this study from October 2015 to October 2017.Visual acuity,refractive error,corneal thickness,and keratometry were compared between the groups before and 1 y postoperatively.RESULTS:The postoperative uncorrected near visual acuity(UNVA)and uncorrected distance visual acuity(UDVA)were improved in the two groups.The UNVA reached J1 in 15 eyes(75.0%)in the s LIKE group and 5 eyes(22.7%)in the FS-LASIK group 1 y after surgery(χ2=11.476,P=0.001).The UDVA was equal or better than the preoperative CDVA in 16 eyes(80.0%)in the s LIKE group and 8 eyes(36.4%)in the FS-LASIK group,respectively(X2=8.145,P=0.004).No eyes lost any line of best-corrected visual acuity(BCVA)in either group.The amount of postoperative residual hyperopia in the s LIKE group was significantly less than in the FS-LASIK group(Z=-2.841,P=0.004).The postoperative keratometry and corneal thickness were significantly higher in the s LIKE group than in the FS-LASIK group(t=4.411,10.279,P<0.001).The SRI and SAI of the s LIKE group were significantly higher than that in the FS-LASIK group.There was no statistically significant difference in mean decentration between the two groups.CONCLUSION:s LIKE has better visual and refractive outcome than FS-LASIK for correction of moderate and high hyperopia.

Endoscopic Assisted Microscopic Fenestration of Inner Membrane in Cases of Chronic Subdural Hematoma

Introduction: Chronic subdural hematoma (CSDH) is one of the most common types of intracranial hemorrhages and carries a significant morbidity;there is no clear optimal treatment. Recurrence, pneumocephaly and seizures are common complications. We will evaluate outcome after inner membrane fenestration in comparison to burr-hole evacuation only in cases of CSDH. Patients and Methods: Our work was conducted on 20 patients with CSDH from February 2017 to July 2017. Endoscopic-assisted microscopic fenestration technique was used to do inner membrane fenestration in ten patients and the other 10 patients operated upon by traditional burr-hole evacuation. Regular follow up was done up to one month. Results: Clinical outcome was nearly the same in the two groups. Recurrence rate was only noted in the non-fenestration group (20%). Midline shift was better in the membrane fenestration group after one month and we experienced no intraoperative surgical complications related to the fenestration technique. Postoperative complications, such as Pneumocephalus and seizures, were seen in both study groups. Conclusion: Endoscopic assisted microscopic technique decreases surgical risks to do inner membrane fenestration although there is no major difference between doing fenestration or not in clinical outcome, but it may decrease recurrence, but larger studies are needed.

Visual outcome of manual small-incision cataract surgery:comparison of modified Blumenthal and Ruit techniques

AIM:To compare the efficacy and visual results of the modified Blumenthal and Ruit techniques for manual small-incision cataract surgery(MSICS).· METHODS:This was a prospective,non-randomized comparison of 129 patients with senile cataracts scheduled to undergo routine cataract surgery via either a superior scleral tunnel incision,i.e.,the Blumenthal technique(group 1,n = 64) or a temporal scleral tunnel incision,i.e.,the Ruit technique(group 2,n =65).MSICS and intraocular lens implantation were performed through an unsutured 6.5-to 7.0-mm scleral tunnel incision.Uncorrected and corrected visual acuity,intraoperative and postoperative complications,and surgically induced astigmatism calculated by simple subtraction were compared.Patients were examined at 1 day,1 week,1 month,and 3 months after surgery.· RESULTS:Both groups achieved good visual outcome with minor complications.Three months after surgery,the corrected visual acuity was 0.73 in the Blumenthal group and 0.69 in the Ruit group(P =0.29).The average(SD) postoperative astigmatism was 0.87(0.62) diopter(D) for the Blumenthal group and 0.86(0.62) D for the Ruit group.The mean(SD) surgically induced astigmatism was 0.55(0.45) D and 0.50(0.44) D for the Blumenthal and Ruit groups,respectively(P =0.52).Common complications were minimal hyphema and corneal edema.There was no statistically significant difference in the complication rate between the groups(P >0.05).· CONCLUSION:In MSICS,both the Blumenthal and Ruit techniques achieved good visual outcomes,with low complication rates.

Open Reduction by Fenestration to the Ilium for Central Acetabular Depression Fractures: A Case Report and Operative Technique

Aim: The aim was to report a fenestration technique for gap reduction of acetabular depression fractures. Case presentation: A 76-year-old man suffered from severe left leg pain. The computed tomography scanning showed a displaced acetabular depression fracture, including a third fracture fragment in the center of the acetabular weight-bearing area. We performed a fenestration technique to fenestrate the outer plate of ilium to push down the dislocated fragment of the fracture. The patient was pain-free with good functional outcome of the hip joint at three years after operation. Conclusion: The fenestration technique is useful for displaced acetabular depression fractures. We performed open reduction in this particular case, but the technique may be done less invasively with the use of hip arthroscopy.

Incidence and risk factors for vitreous loss in residents performing manual small-incision cataract surgery

AIM: To assess the incidence of vitreous loss and associated risk factors in residents performing manual small-incision cataract surgery(MSICS). METHODS: The present retrospective record review study was performed on 490 patients who underwent MSICS performed between November 2018 and December 2019 by 7 third-year postgraduate residents. The study group comprised of patients having intraoperative vitreous prolapse. All the surgeries were performed under supervision of a trained assistant. RESULTS: The mean age of the participants at the time of surgery was 68.42±2.05 y. Of the 490 patients, 250 patients were male, and 240 patients were female(P=0.23). A total of 215(43.9%) eyes had mature white cataract, 185(37.8%) eyes had brown cataract, and 90(18.3%) eyes had immature senile cataract. The incidence of intraoperative vitreous loss among residents was 2%(10/490). Vitreous loss occurred during hydrodissection [1/10(10%)], nucleus delivery [3/10(30%)], irrigation and aspiration [5/10(50%)], and intraocular lens insertion [1/10(10%)]. Multivariate stepwise Logistic regression analysis confirmed immature senile cataract [odds ratio(OR)=3.99;P=0.02], irrigation and aspiration of cortical material(OR=3.07;P=0.03), and anterior capsular extension(OR=3.22, P=0.03) as independent risk factors for vitreous loss. CONCLUSION: Immature senile cataract, irrigation and aspiration of cortical material, and anterior capsular extension are independent risk factors for vitreous loss. Our findings may serve as a guide for future trainers or residents learning MSICS.

Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess:A case report and review of literature

BACKGROUND Abscess formation is one of the complications after radical resection of rectal cancer;cases with delayed postoperative anastomotic abscess are rare.Here,we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery.Ultimately,the patient was diagnosed and treated by endoscopic fenestration.In addition,we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.CASE SUMMARY A 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma.Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria,and a submucosal tumor was suspected.The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography,which revealed no thickening or strengthening of the anastomotic wall.In order to clarify the origin of the lesion and obtain the pathology,endoscopic fenestration was performed.After endoscopic procedure,a definitive diagnosis of delayed anastomotic submucosal abscess was established.The patient achieved good recovery and prognosis after the complete clearance of abscess.CONCLUSION Endoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.

Antegrade in situ laser fenestration of aortic stent graft during endovascular aortic repair:A case report

BACKGROUND The endovascular repair of juxtarenal abdominal aortic aneurysms(JAAA)usually requires combination treatment with various stent graft modifications to preserve side branch patency.As a feasible technique,according to the situation,antegrade in situ laser fenestration still needs to be improved.CASE SUMMARY This report describes a case that was successfully treated with endovascular repair facilitated by antegrade in situ laser fenestration while maintaining renal arterial flow.Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of the renal artery ostium.With the bare stent region unreleased,renal artery perfusion could be maintained and accurate positioning could be achieved by angiography in real time.CONCLUSION This study suggests the feasibility and short-term safety of this novel antegrade in situ laser fenestration technique for select JAAA patients.

Delayed diffuse lamellar keratitis after small-incision lenticule extraction related to immunoglobulin A nephropathy:A case report

BACKGROUND Diffuse lamellar keratitis(DLK)is a complication of laser-assisted in situ keratomileusis(LASIK).This condition can also develop after small-incision lenticule extraction(SMILE)with a distinctive appearance.We report the case involving a female patient with delayed onset DLK accompanied by immunoglobulin A(IgA)nephropathy.CASE SUMMARY A 22-year-old woman was referred to our department for DLK and a decline in vision 1 mo after undergoing SMILE.The initial examination showed grade 2 DLK in the flap involving the central visual axis of the right eye.She was immediately administered with a large dose of a topical steroid for 30 d.However,the treatment was ineffective.Her vision deteriorated from 10/20 to 6/20,and DLK gradually worsened from grade 2 to 4.Eventually,interface washout was performed,after which her vision improved.DLK completely disappeared 2 mo after washout.Six months after SMILE,the patient was diagnosed with IgA nephropathy due to a 4-year history of interstitial hematuria.CONCLUSION DLK is a typical complication of LASIK but can also develop after SMILE.Topical steroid therapy was ineffective in our patient,and interface washout was required.IgA nephropathy could be one of the factors contributing to the development of delayed DLK after SMILE.

Laparoscopic fenestration of pancreatic serous cystadenoma:Minimally invasive approach for symptomatic benign disease

Serous cystadenoma(SC) is a benign pancreatic cystic tumor. Surgical resection is recommended for symptomatic forms, but laparoscopic fenestration of large symptomatic macrocystic SC was not yet described in the literature. In this study, 3 female patients underwent laparoscopic fenestration for macrocystic SC(12-14 cm). Diagnosis was established via magnetic resonance imaging and endoscopic ultrasound, with intra-cystic dosage of tumors markers(ACE and CA19-9) in 2 patients. All patients were symptomatic and operated on 15-60 mo after diagnosis.Radiological evaluation showed constant cyst growth.Patients were informed about this new surgical modality that can avoid pancreatic resection. The mean operative time was 103 min(70-150 min) with one conversion.The post-operative course was marked by a grade A pancreatic fistula in one patient and was uneventful in the other two. The hospital stay was 3, 10, and 18 d, respectively. The diagnosis of macrocystic SC was histologically-confirmed in all cases. At the last followup(13-26 mo), all patients were symptom-free, and radiological evaluation showed complete disappearance of the cyst. Laparoscopic fenestration, as opposed to resection, should be considered for large symptomatic macrocystic SC, thereby avoiding pancreatic resection morbidity and mortality.

Shunting,optic nerve sheath fenestration and dural venous stenting for medically refractory idiopathic intracranial hypertension:systematic review and meta-analysis

Background:Cerebrospinal fluid(CSF)-diversion procedures have traditionally been the standard of treatment for patients with medically refractive idiopathic intracranial hypertension(IIH).However,dural venous sinus stent(VSS)placement has been described as a safe and effective procedure for the management of medically refractive IIH.We performed a meta-analysis comparing outcomes and complications of CSF-diversion procedures,VSS and optic nerve sheath fenestration(ONSF)for the treatment of medically refractive IIH.Methods:Electronic searches were performed using six databases from 1988 to January 2017.Data was extracted and meta-analysed from the identified studies.Results:From 55 pooled studies,there were 538 CSF-diversion cases,224 dural venous stent placements,and 872 ONSF procedures.Similar improvements were found in terms of postoperative headaches(CSF vs.VSS vs.ONSF:84%vs.78%vs.62%,P=0.223),papilledema(CSF vs.VSS vs.ONSF:71%vs.86%vs.77%,P=0.192),whilst visual acuity changes favored venous stenting(CSF vs.VSS vs.ONSF:55%vs.69%vs.44%,P=0.037).There was a significantly lower rate of subsequent procedures with venous stent placement(CSF vs.VSS vs.ONSF:37%vs.13%vs.18%,P<0.001),but other complication rates were similar(CSF vs.VSS vs.ONSF:13%vs.8%vs.14%,P=0.28).Subgroup analysis of lumbar-peritoneal vs.ventriculoperitoneal shunts found no differences in symptom improvements,complications and subsequent procedure rates.Conclusions:Our findings suggest that dural venous sinus stenting may be a viable alternative to traditional surgical interventions in patients who are refractory to medical treatment.