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World Journal of Surgical Oncology Jul 2016In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by restoration of biliary flow prior to operation. This is a meta-analysis to pool the evidence and assess the utility of PBD in patients with malignant obstructive jaundice. The primary outcome is comparing mortality outcomes in patients with malignant obstructive jaundice undergoing direct surgery (DS) versus PBD. The secondary outcomes include major adverse events and length of hospital stay in both the groups.
METHODS
Studies using PBD in patients with malignant obstructive jaundice were included in this study. For the data collection and extraction, articles were searched in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, etc. Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model).
RESULTS
Initial search identified 2230 reference articles, of which 204 were selected and reviewed. Twenty-six studies (N = 3532) for PBD in malignant obstructive jaundice which met the inclusion criteria were included in this analysis. The odds ratio for mortality in PBD group versus DS group was 0.96 (95 % CI = 0.71 to 1.29). Pooled number of major adverse effects was lower in the PBD group at 10.40 (95 % CI = 9.96 to 10.83) compared to 15.56 (95 % CI = 15.06 to 16.05) in the DS group. Subgroup analysis comparing internal PBD to DS group showed lower odds for major adverse events (odds ratio, 0.48 with 95 % CI = 0.32 to 0.74).
CONCLUSIONS
In patients with malignant biliary jaundice requiring surgery, PBD group had significantly less major adverse effects than DS group. Length of hospital stay and mortality rate were comparable in both the groups.
Topics: Biliary Tract Neoplasms; Biliary Tract Surgical Procedures; Drainage; Duodenal Neoplasms; Humans; Jaundice, Obstructive; Length of Stay; Odds Ratio; Pancreatic Neoplasms; Postoperative Complications; Preoperative Care; Randomized Controlled Trials as Topic
PubMed: 27400651
DOI: 10.1186/s12957-016-0933-2 -
Internal Medicine (Tokyo, Japan) Oct 2019Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully...
Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.
Topics: Ampulla of Vater; Common Bile Duct Neoplasms; Electrosurgery; Endoscopy, Digestive System; Humans; Treatment Outcome
PubMed: 31243201
DOI: 10.2169/internalmedicine.2720-19 -
American Journal of Surgery Dec 2018Parenchyma-sparing, local pancreatic head resection, but not pancreaticoduodenectomy (PD) preserves tissue and maintains the pancreatic metabolic functions. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Parenchyma-sparing, local pancreatic head resection, but not pancreaticoduodenectomy (PD) preserves tissue and maintains the pancreatic metabolic functions.
METHODS
PubMed/Medline, Embase, and Cochrane library collections were systematically searched. Twenty-six cohort studies with 523 cumulative patients, who underwent duodenum-sparing pancreatic head resection (DPPHR), were retrieved. The meta-analysis was based on 14 controlled studies.
RESULTS
In total, 338 patients suffered cystic neoplasms and 59 PNETs, IPMN-174, MCN-43 and SPN-23 patients. Eighty-one patients (15.5%) histo-pathologically displayed a low-malignant tumor, of which 27 were carcinoma in-situ. Tumor recurrence was observed after a mean follow-up of 47.1 months in 11 patients. In-hospital and late mortality after DPPHR was 0.6% and 1.7%, respectively. The meta-analysis was based on 318 DPPHR compared to 404 PD patients. DPPHR was performed for premalignant neoplasm and PNET in 164 and 46 patients, and PD in 181 and 46 patients, respectively. Events of recurrence displayed no statistically significant difference between the DPPHR and PD groups.
CONCLUSION
DPPHR is associated with oncologically complete tumor resection for patients suffering premalignant IPMN, MCN, or SPN and for low-risk cancer.
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Precancerous Conditions
PubMed: 30366596
DOI: 10.1016/j.amjsurg.2018.10.003 -
Annals of Medicine and Surgery (2012) Oct 2022Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of... (Review)
Review
BACKGROUND
Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding.
MATERIALS AND METHOD
Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software.
RESULT
Two RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant.
CONCLUSION
The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies.
PubMed: 36268446
DOI: 10.1016/j.amsu.2022.104618 -
Langenbeck's Archives of Surgery Mar 2018Predicting the biologic behavior of intraductal papillary mucinous neoplasm (IPMN) remains challenging. Current guidelines utilize patient symptoms and imaging... (Review)
Review
Can we better predict the biologic behavior of incidental IPMN? A comprehensive analysis of molecular diagnostics and biomarkers in intraductal papillary mucinous neoplasms of the pancreas.
PURPOSE
Predicting the biologic behavior of intraductal papillary mucinous neoplasm (IPMN) remains challenging. Current guidelines utilize patient symptoms and imaging characteristics to determine appropriate surgical candidates. However, the majority of resected cysts remain low-risk lesions, many of which may be feasible to have under surveillance. We herein characterize the most promising and up-to-date molecular diagnostics in order to identify optimal components of a molecular signature to distinguish levels of IPMN dysplasia.
METHODS
A comprehensive systematic review of pertinent literature, including our own experience, was conducted based on the PRISMA guidelines.
RESULTS
Molecular diagnostics in IPMN patient tissue, duodenal secretions, cyst fluid, saliva, and serum were evaluated and organized into the following categories: oncogenes, tumor suppressor genes, glycoproteins, markers of the immune response, proteomics, DNA/RNA mutations, and next-generation sequencing/microRNA. Specific targets in each of these categories, and in aggregate, were identified by their ability to both characterize a cyst as an IPMN and determine the level of cyst dysplasia.
CONCLUSIONS
Combining molecular signatures with clinical and imaging features in this era of next-generation sequencing and advanced computational analysis will enable enhanced sensitivity and specificity of current models to predict the biologic behavior of IPMN.
Topics: Adenocarcinoma, Mucinous; Biomarkers, Tumor; Biopsy, Needle; Carcinoma, Pancreatic Ductal; Female; Humans; Immunohistochemistry; Incidental Findings; Male; MicroRNAs; Needs Assessment; Pancreatic Neoplasms; Pathology, Molecular; Practice Guidelines as Topic; Predictive Value of Tests; Prognosis; Risk Factors
PubMed: 29218397
DOI: 10.1007/s00423-017-1644-z -
Journal of Clinical Gastroenterology Jul 2024There is an increasing interest in cold snare endoscopic mucosal resection (CS-EMR), and studies have shown its safety and efficacy for colonic polyps. This... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
There is an increasing interest in cold snare endoscopic mucosal resection (CS-EMR), and studies have shown its safety and efficacy for colonic polyps. This meta-analysis aims to assess the safety and efficacy of CS-EMR for the removal of duodenal adenomas.
METHODS
We conducted a comprehensive literature search of several databases, from inception through February 2023, for studies that addressed outcomes of CS-EMR for nonampullary duodenal adenomas. We used the random-effects model for the statistical analysis. The weighted pooled rates were used to summarize the technical success, polyp recurrence, bleeding, and perforation events. Cochran Q test and I2 statistics adjudicated heterogeneity.
RESULTS
Six studies were included in the analysis. In all, 178 duodenal polyps were resected using CS-EMR. The pooled rates were 95.8% (95% CI 89.1-98.5%, I2 =21.5%) for technical success and 21.2% (95% CI 8.5-43.6%, I2 =78%) for polyp recurrence. With regards to CS-EMR safety, the pooled rates were 4.2% (95% CI 1.6-10.5%, I2 =12%) for immediate bleeding, 3.4% (95% CI 1.5-7.6%, I2 =0%) for delayed bleeding, 2.8% (95% CI 1.1-6.7%, I2 =0%) for perforation, and 2% (95% CL 0.5-7.5%, I2 =0%) for post-polypectomy syndrome. Rates were not significantly different for large adenomas. Three studies reported data on CS-EMR and conventional EMR. Compared with conventional EMR, CS-EMR had lower odds of delayed bleeding, OR 0.11 (CI 0.02-0.62, P value 0.012, I2 =0%).
CONCLUSION
Our findings suggest that CS-EMR is a safe and effective strategy for the resection of nonampullary duodenal adenomas, with an acceptable recurrence rate. Data from larger randomized controlled studies are needed to validate our findings.
Topics: Humans; Endoscopic Mucosal Resection; Duodenal Neoplasms; Intestinal Polyps; Adenoma; Treatment Outcome; Neoplasm Recurrence, Local
PubMed: 37548451
DOI: 10.1097/MCG.0000000000001898 -
Gastrointestinal Endoscopy Feb 2021Although various procedures have been used to prevent serious adverse events after endoscopic resection of the duodenum, their effectiveness has not been determined. In... (Meta-Analysis)
Meta-Analysis Review
Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials.
BACKGROUND AND AIMS
Although various procedures have been used to prevent serious adverse events after endoscopic resection of the duodenum, their effectiveness has not been determined. In this study, we conducted a systematic review and meta-analysis to determine whether endoscopic preventive procedures reduce delayed adverse events.
METHODS
Studies on endoscopic treatment for superficial nonampullary duodenal tumors were selected. We compared the following 2 groups: the closure group, which underwent mucosal sutures and coverage of mucosal defects after resection, and the unclosed group, which did not. The primary outcome was the rate of delayed adverse events, including perforation and bleeding. The pooled risk ratios (RRs) of all outcomes investigated, the 95% confidence intervals (CIs), and P values were calculated.
RESULTS
A total of 438 patients from 4 studies were included in the meta-analysis. The pooled overall adverse event rates in the closure group and unclosed group were 3.6% and 21.1%, respectively. This rate was significantly lower in the closure group (RR, 0.19; 95% CI, 0.10-0.38; P < .01; I = 0%), and the rate of delayed bleeding was significantly lower in the closure group (RR, 0.14; 95% CI, 0.06-0.33; P < .01; I = 0%). Regarding delayed perforation, the RR in the closure group was 0.39 (95% CI, 0.12-1.32; P = .13; I = 0%).
CONCLUSIONS
Preventive procedures significantly reduced the risk of delayed adverse events by more than 80%. After endoscopic resection of the duodenum, the implementation of preventive procedures, including mucosal sutures and coverage of mucosal defects, to delay adverse events is strongly recommended.
Topics: Duodenal Neoplasms; Duodenum; Endoscopic Mucosal Resection; Endoscopy; Humans; Neoplasms, Glandular and Epithelial
PubMed: 32835670
DOI: 10.1016/j.gie.2020.08.017 -
World Journal of Gastroenterology May 2018The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical... (Review)
Review
Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature.
The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.
Topics: Biliary Tract Neoplasms; Gastric Bypass; Gastric Outlet Obstruction; Humans; Jaundice, Obstructive; Laparoscopy; Palliative Care; Pancreatic Neoplasms; Patient Selection; Quality of Life; Stents; Stomach Neoplasms; Treatment Outcome
PubMed: 29760541
DOI: 10.3748/wjg.v24.i18.1978 -
BMC Surgery May 2019Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient's life. DSF is related to...
BACKGROUND
Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient's life. DSF is related to high mortality (16-20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer.
METHODS
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.
RESULTS
The 20 included articles covered an approximately 40 years-study period (1979-2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21-39 days, ranging from 1 to 1035 days. Healing time was 19-63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%.
CONCLUSIONS
DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.
Topics: Abdominal Abscess; Duodenal Diseases; Gastrectomy; Humans; Intestinal Fistula; Peritonitis; Postoperative Complications; Stomach Neoplasms; Wound Healing
PubMed: 31138190
DOI: 10.1186/s12893-019-0520-x -
Journal of Vascular and Interventional... May 2018To compare postoperative complications in patients who underwent pancreatoduodenectomy after either endoscopic or percutaneous biliary drain (BD). (Meta-Analysis)
Meta-Analysis Review
Is Percutaneous Transhepatic Biliary Drainage Better than Endoscopic Drainage in the Management of Jaundiced Patients Awaiting Pancreaticoduodenectomy? A Systematic Review and Meta-analysis.
PURPOSE
To compare postoperative complications in patients who underwent pancreatoduodenectomy after either endoscopic or percutaneous biliary drain (BD).
MATERIAL AND METHODS
Data from studies comparing the rate of postoperative complications in patients who underwent endoscopic BD or percutaneous BD before pancreatoduodenectomy were extracted independently by 2 investigators. The primary outcome compared in the meta-analysis was the risk of postoperative complications. Secondary outcomes were the risks of procedure-related complications, postoperative mortality, postoperative pancreatic fistula, severe complications, and wound infection. For dichotomous variables, the odds ratio (OR) with 95% confidence interval (CI) was calculated.
RESULTS
Thirteen studies, including 2334 patients (501 in the percutaneous BD group and 1833 in the endoscopic group), met the inclusion criteria. Postoperative and procedure-related complication rates were significantly lower in the percutaneous BD group (OR = .7, 95% CI = .52-.94, P = .02 and OR = .44, 95% CI = .23-.84, P = .01, respectively). No significant differences were observed when severe postoperative complications, postoperative mortality, postoperative pancreatic fistula, and wound infection rates were compared.
CONCLUSIONS
In patients awaiting pancreatoduodenectomy, preoperative percutaneous BD is associated with fewer procedure-related or postoperative complications than endoscopic drain.
Topics: Bile Duct Neoplasms; Cholangiocarcinoma; Cholangiopancreatography, Endoscopic Retrograde; Drainage; Duodenal Neoplasms; Endoscopy; Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 29548873
DOI: 10.1016/j.jvir.2017.12.027