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Surgical Endoscopy Nov 2022Transmural EUS-guided gallbladder drainage (EUS-GBD) has been increasingly used in the treatment of gallbladder diseases. Aims of the study were to provide a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
Transmural EUS-guided gallbladder drainage (EUS-GBD) has been increasingly used in the treatment of gallbladder diseases. Aims of the study were to provide a comprehensive meta-analysis and meta-regression of features and outcomes of this procedure.
METHODS
MEDLINE, Scopus, Web of science, and Cochrane databases were searched for literature pertinent to transmural EUS-GBD up to May 2021. Random-effect meta-analysis of proportions and meta-regression of potential modifiers of outcome measures considered were applied. Outcome measures were technical success rate, overall clinical success, and procedure-related adverse events (AEs).
RESULTS
Twenty-seven articles were identified including 1004 patients enrolled between February 2009 and February 2020. Acute cholecystitis was present in 98.7% of cases. Pooled technical success was 98.0% (95% CI 96.3, 99.3; heterogeneity: 23.6%), the overall clinical success was 95.4% (95% CI 92.8, 97.5; heterogeneity: 35.3%), and procedure-related AEs occurred in 14.8% (95% CI 8.8, 21.8; heterogeneity: 82.4%), being stent malfunction/dislodgement the most frequent (3.5%). Procedural-related mortality was 1‰. Meta-regression showed that center experience proxied to > 10 cases/year increased the technical success rate (odds ratio [OR]: 2.84; 95% CI 1.06, 7.59) and the overall clinical success (OR: 3.52; 95% CI 1.33, 9.33). The use of anti-migrating devices also increased the overall clinical success (OR: 2.16; 95% CI 1.07, 4.36) while reducing procedure-related AEs (OR: 0.36; 95% CI 0.14, 0.98).
CONCLUSION
Physicians' experience and anti-migrating devices are the main determinants of main clinical outcomes after EUS-GBD, suggesting that treatment in expert centers would optimize results.
Topics: Humans; Gallbladder; Endosonography; Drainage; Cholecystitis, Acute; Stents; Treatment Outcome
PubMed: 35652964
DOI: 10.1007/s00464-022-09339-y -
Journal of Laparoendoscopic & Advanced... Nov 2021Percutaneous gallbladder drainage (PTGBD), endoscopic ultrasound-guided gallbladder drainage (EUSGBD), and endoscopic transpapillary gallbladder drainage (ETGBD) are... (Meta-Analysis)
Meta-Analysis
Percutaneous gallbladder drainage (PTGBD), endoscopic ultrasound-guided gallbladder drainage (EUSGBD), and endoscopic transpapillary gallbladder drainage (ETGBD) are used for the treatment of patients with acute cholecystitis who are at high surgical risk. However, it is unclear which procedure is associated with the best outcomes. We systematically searched records in PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov up to March 1, 2020. Studies that compared at least two of PTGBD, ETGBD, and EUSGBD were included. A total of 13 studies were included in the present analyses. PTGBD, EUSGBD, and ETGBD were associated with similar clinical success, adverse event, recurrent cholecystitis, reintervention, and mortality rates. PTGBD was associated with a higher technical success rate than EUSGBD (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.40-1.41) or ETGBD (OR = 0.73, 95% CI = 0.35-1.53). EUSGBD was associated with the highest probability of clinical success (67.5%), and the lowest prevalences of adverse events (57.0%) and recurrent cholecystitis (60.9%). ETGBD was associated with the best reintervention outcomes (81.8%). Compared with PTGBD and ETGBD, EUSGBD appears to be preferable with respect to both safety and efficacy for the treatment of patients with acute cholecystitis who are at high surgical risk.
Topics: Cholecystitis, Acute; Drainage; Endosonography; Gallbladder; Humans; Network Meta-Analysis
PubMed: 33416417
DOI: 10.1089/lap.2020.0897 -
Health Technology Assessment... Aug 2014Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of... (Comparative Study)
Comparative Study Review
Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation.
BACKGROUND
Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.
OBJECTIVES
To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.
DATA SOURCES
We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.
REVIEW METHODS
Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.
RESULTS
Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.
CONCLUSIONS
The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.
STUDY REGISTRATION
The study was registered as PROSPERO CRD42012002817.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Adult; Cholecystectomy; Cholecystitis; Cost-Benefit Analysis; Female; Gallstones; Humans; Male; Recurrence; Treatment Outcome; Watchful Waiting
PubMed: 25164349
DOI: 10.3310/hta18550 -
Journal of Laparoendoscopic & Advanced... Nov 2021To compare the safety and effectiveness of endoscopic ultrasound-guided gallbladder drainage (EUSGBD) with percutaneous transhepatic gallbladder drainage (PTGBD) for... (Meta-Analysis)
Meta-Analysis
Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis with High Surgical Risk: An Up-to-Date Meta-Analysis and Systematic Review.
To compare the safety and effectiveness of endoscopic ultrasound-guided gallbladder drainage (EUSGBD) with percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis with high surgical risk. An electronic search was performed of the major databases, namely PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until July 1, 2020. Studies comparing EUSGBD with PTGBD were included. We identified 8 studies involving 801 patients, and patients were divided into two groups (EUSGBD group = 338 and PTGBD = 463). EUSGBD was associated with less reintervention (odds ratio [OR] = 0.15; 95% confidence interval [CI]: 0.07-0.32; < .00001) and readmission (OR = 0.24; 95% CI: 0.08-0.67; = 7). With lumen-apposing metal stents (LAMS), EUSGBD was associated with fewer adverse events (OR = 0.35; 95% CI: 0.13-0.93; = .03), recurrent cholecystitis (OR = 0.27; 95% CI: 0.10-0.71; = .008) and readmission (OR = 0.10; 95% CI: 0.03-0.32; = .0001). There were no significant differences between the groups regarding clinical success (OR = 1.47; 95% CI: 0.75-2.90; = .26). Technical success with PTGBD was higher than that with EUSGBD (OR = 0.32; 95% CI: 0.13-0.83; = .02). EUSGBD was comparable with PTGBD regarding clinical success, with less reintervention and readmission, for acute cholecystitis with high surgical risk. The cholecystitis recurrence rate was lower with EUSGBD with LAMS.
Topics: Cholecystitis, Acute; Cholecystostomy; Drainage; Gallbladder; Humans; Treatment Outcome; Ultrasonography, Interventional
PubMed: 33400595
DOI: 10.1089/lap.2020.0786 -
European Radiology May 2024Some patients undergo both computed tomography (CT) and ultrasound (US) sequentially as part of the same evaluation for acute cholecystitis (AC). Our goal was to perform...
OBJECTIVES
Some patients undergo both computed tomography (CT) and ultrasound (US) sequentially as part of the same evaluation for acute cholecystitis (AC). Our goal was to perform a systematic review and meta-analysis comparing the diagnostic performance of US and CT in the diagnosis of AC.
MATERIALS AND METHODS
Databases were searched for relevant published studies through November 2023. The primary objective was to compare the head-to-head performance of US and CT using surgical intervention or clinical follow-up as the reference standard. For the secondary analysis, all individual US and CT studies were analyzed. The pooled sensitivities, specificities, and areas under the curve (AUCs) were determined along with 95% confidence intervals (CIs). The prevalence of imaging findings was also evaluated.
RESULTS
Sixty-four studies met the inclusion criteria. In the primary analysis of head-to-head studies (n = 5), CT had a pooled sensitivity of 83.9% (95% CI, 78.4-88.2%) versus 79.0% (95% CI, 68.8-86.6%) of US (p = 0.44). The pooled specificity of CT was 94% (95% CI, 82.0-98.0%) versus 93.6% (95% CI, 79.4-98.2%) of US (p = 0.85). The concordance of positive or negative test between both modalities was 82.3% (95% CI, 72.1-89.4%). US and CT led to a positive change in management in only 4 to 8% of cases, respectively, when ordered sequentially after the other test.
CONCLUSION
The diagnostic performance of CT is comparable to US for the diagnosis of acute cholecystitis, with a high rate of concordance between the two modalities.
CLINICAL RELEVANCE STATEMENT
A subsequent US after a positive or negative CT for suspected acute cholecystitis may be unnecessary in most cases.
KEY POINTS
When there is clinical suspicion of acute cholecystitis, patients will often undergo both CT and US. CT has similar sensitivity and specificity compared to US for the diagnosis of acute cholecystitis. The concordance rate between CT and US for the diagnosis of acute cholecystitis is 82.3%.
PubMed: 38758253
DOI: 10.1007/s00330-024-10783-8 -
Cureus Oct 2023This systematic review aims to review articles that evaluate the risk of conversion from laparoscopic to open cholecystectomy and to analyze the identified preoperative... (Review)
Review
This systematic review aims to review articles that evaluate the risk of conversion from laparoscopic to open cholecystectomy and to analyze the identified preoperative and intraoperative risk factors. The bibliographic databases CINAHL, Cochrane, Embase, Medline, and PubMed were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language retrospective studies and systematic reviews with more than 200 patients were included. The time of publication was limited from 2012 to 2022. Our systematic review identified 30 studies with a total of 108,472 patients. Of those, 92,765 cholecystectomies were commenced laparoscopically and 5,477 were converted to open cholecystectomy (5.90%). The rate of conversion ranges from 2.50% to 50%. Older males with acute cholecystitis, previous abdominal surgery, symptom duration of more than 72 hours, previous history of acute cholecystitis, C-reactive protein (CRP) value of more than 76 mg/L, diabetes, and obesity are significant preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Significant intraoperative risk factors for conversion include gallbladder inflammation, adhesions, anatomic difficulty, Nassar scale of Grades 3 to 4, Conversion from Laparoscopic to Open Cholecystectomy (CLOC) score of more than 6 and 10-point gallbladder operative scoring system (G10) score more than 3.
PubMed: 38021611
DOI: 10.7759/cureus.47774 -
Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis.Przeglad Gastroenterologiczny 2021Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery. (Review)
Review
INTRODUCTION
Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery.
AIM
This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy.
MATERIAL AND METHODS
An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables.
RESULTS
There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; < 0.0001).
CONCLUSIONS
This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.
PubMed: 34584579
DOI: 10.5114/pg.2020.100658 -
Updates in Surgery Apr 2021Laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) are common treatments for patients with acute cholecystitis. However, the safety... (Meta-Analysis)
Meta-Analysis
Comparison of emergency cholecystectomy and delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute cholecystitis: a systematic review and meta-analysis.
Laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) are common treatments for patients with acute cholecystitis. However, the safety and efficacy of emergency laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) after PTGBD in patients with acute cholecystitis remain unclear. The PubMed, EMBASE, and Cochrane Library databases were searched through October 2019. The quality of the included nonrandomized studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS). The meta-analysis was performed using STATA version 14.2. A random-effects model was used to calculate the outcomes. A total of fifteen studies involving 1780 patients with acute cholecystitis were included in the meta-analysis. DLC after PTGBD was associated with a shorter operative time (SMD - 0.51; 95% CI - 0.89 to - 0.13; P = 0.008), a lower conversion rate (RR 0.43; 95% CI 0.26 to 0.69; P = 0.001), less intraoperative blood loss (SMD - 0.59; 95% CI - 0.96 to - 0.22; P = 0.002) and longer time of total hospital stay compared to ELC (SMD 0.91; 95% CI 0.57-1.24; P < 0.001). There was no difference in the postoperative complications (RR 0.68; 95% CI 0.48-0.97; P = 0.035), biliary leakage (RR 0.65; 95% CI 0.34-1.22; P = 0.175) or mortality (RR 1.04; 95% CI 0.39-2.80; P = 0.933). Compared to ELC, DLC after PTGBD had the advantages of a shorter operative time, a lower conversion rate and less intraoperative blood loss.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Drainage; Humans; Retrospective Studies; Treatment Outcome
PubMed: 33048340
DOI: 10.1007/s13304-020-00894-4 -
Surgical Endoscopy May 2020In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD.
METHODS
We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated.
RESULTS
Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03-13.44; p = 0.0006; I = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00-8.66; p = 0.0001; I = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77-2.22; p = 0.33, I = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14-0.79; p = 0.01; I = 0%)]. There was low heterogeneity in the analyses.
CONCLUSION
EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.
Topics: Aged; Cholecystitis; Cholecystitis, Acute; Endoscopy; Female; Gallbladder; Humans; Male; Retrospective Studies
PubMed: 32048019
DOI: 10.1007/s00464-020-07409-7 -
The Cochrane Database of Systematic... Sep 2016Cholelithiasis refers to the presence of gallstones, which are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis is one of the most... (Review)
Review
BACKGROUND
Cholelithiasis refers to the presence of gallstones, which are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis is one of the most common surgical problems worldwide and is particularly prevalent in most Western countries.Biliary colic is the term used for gallbladder pain experienced by a person with gallstones and without overt infection around the gallbladder. It is the most common manifestation of cholelithiasis, observed in over one-third of people with gallstones over the course of 10 or more years. Non-steroid anti-inflammatory drugs (NSAIDs) have been widely used to relieve biliary colic pain, but their role needs further elucidation. They may decrease the frequency of short-term complications, such as mild form of acute cholecystitis, jaundice, cholangitis, and acute pancreatitis, but they may also increase the occurrence of more severe and possibly life-threatening adverse events such as gastrointestinal bleeding, renal function impairment, cardiovascular events, or milder events such as abdominal pain, drowsiness, headache, dizziness, or cutaneous manifestations.
OBJECTIVES
To assess the benefits and harms of NSAIDs in people with biliary colic.
SEARCH METHODS
We searched the Cochrane Hepato-Biliary Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), Science Citation Index Expanded (Web of Science), and ClinicalTrials.gov until July 2016. We applied no language limitation.
SELECTION CRITERIA
Randomised clinical trials recruiting participants presenting with biliary colic and comparing NSAIDs versus no intervention, placebo, or other drugs.
DATA COLLECTION AND ANALYSIS
Two review authors (MF and AC) independently identified trials for inclusion. We used risk ratios (RR) to express intervention effect estimates, and we analysed the data with both fixed-effect and random-effects model meta-analyses, depending on the amount of heterogeneity. We controlled random errors with Trial Sequential Analysis. We assessed the methodological quality of the evidence using GRADE criteria.
MAIN RESULTS
Twelve randomised clinical trials (RCTs) met our predefined review protocol criteria for analysis. We found only one trial to be at low risk of bias, considering the remaining trials to be at high risk of bias. The risk of selection bias in nine studies was unclear due to poor reporting, leading to uncertainty in the pooled effect estimates. Five trials compared NSAIDs versus placebo, four trials compared NSAID versus opioids, and four trials compared NSAID versus spasmolytic drugs (one of the 12 trials was a three-arm study comparing NSAIDs versus both opioids and spasmolytic drugs). There were 828 randomised participants (minimum 30 and maximum 324 per trial), of whom 416 received NSAIDs and 412 received placebo, spasmolytic drugs, or opioids. Twenty-four per cent of the participants were males. The age of the participants in the trials ranged from 18 to 86 years. All people were admitted to emergency departments for acute biliary pain. There was no mortality. When compared with placebo, NSAIDs obtained a significantly lower proportion of participants without complete pain relief (RR 0.27, 95% confidence interval (CI) 0.19 to 0.40; I = 0%; 5 trials; moderate-quality evidence), which was confirmed by Trial Sequential Analysis, but not regarding participants with complications (RR 0.66, 95% CI 0.38 to 1.15; I = 26%; 3 trials; very low-quality evidence). NSAIDs showed more pain control than spasmolytic drugs (RR 0.51, 95% CI 0.37 to 0.71; I = 0%; 4 trials; low-quality evidence), which was not confirmed by Trial Sequential Analysis, and a significantly lower proportion of participants with complications (RR 0.27, 95% CI 0.12 to 0.57; I = 0%; 2 trials; low-quality evidence), which was also not confirmed by Trial Sequential Analysis. We found no difference in the proportions of participants without complete pain relief when comparing NSAIDs versus opioids (RR 0.98, 95% CI 0.47 to 2.07; I = 52%), suggesting moderate heterogeneity among trials (4 trials; very low-quality evidence). Only one trial comparing NSAIDs versus opioids reported results on complications, finding no significant difference between treatments. None of the included trials reported severe adverse events. Seven out of the 12 trials assessed non-severe adverse events: in two out of the seven trials, adverse events were not observed, and minor events were reported in the remaining five trials.In addition, we found one ongoing RCT assessing the analgesic efficacy of intravenous ibuprofen in biliary colic.
AUTHORS' CONCLUSIONS
NSAIDs have been assessed in relatively few trials including a limited number of participants for biliary colic, considering its common occurrence. We found only one trial to be at low risk of bias. There was no mortality. None of the included trials reported quality of life. The generalisability of the review is low as most of the RCTs included neither elderly people nor participants with comorbidities, who are more prone to complications as compared to others with biliary colic.The beneficial effect of NSAIDs compared with placebo on pain relief was confirmed when we applied Trial Sequential Analysis.The quality of evidence according to GRADE criteria was moderate for the comparison of NSAIDs versus placebo regarding the outcome lack of pain relief and low or very low for the other outcomes and comparisons.We found only one trial at low risk of bias, following the predefined 'Risk of bias' domains. We found the risk of selection bias to be unclear in nine studies due to poor reporting, leading to uncertainty in the pooled effect estimates.
PubMed: 27610712
DOI: 10.1002/14651858.CD006390.pub2