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World Journal of Gastroenterology Jun 2015To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer. (Review)
Review
AIM
To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.
METHODS
A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.
RESULTS
In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.
CONCLUSION
Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.
Topics: Anastomotic Leak; Drainage; Duodenal Diseases; Duodenum; Gastrectomy; Humans; Intestinal Fistula; Length of Stay; Reoperation; Stomach Neoplasms; Time Factors; Treatment Outcome; Wound Healing
PubMed: 26140005
DOI: 10.3748/wjg.v21.i24.7571 -
Journal of Pain Research 2018Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been... (Review)
Review
Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been reported to reduce pain in LAPC. Stereotactic RT (SBRT) is considered as an emerging radiotherapy technique able to achieve high local control rates with acceptable toxicity. However, its role in pain palliation is not clear. To review the impact on pain relief with SBRT in LAPC patients, a literature search was performed on PubMed, Scopus, and Embase (January 2000-December 2017) for prospective and retrospective articles published in English. Fourteen studies (479 patients) reporting the effect of SBRT on pain relief were finally included in this analysis. SBRT was delivered with both standard and/or robotic linear accelerators. The median prescribed SBRT doses ranged from 16.5 to 45 Gy (median: 27.8 Gy), and the number of fractions ranged from 1 to 6 (median: 3.5). Twelve of the 14 studies reported the percentage of pain relief (in patients with pain at presentation) with a global overall response rate (complete and partial response) of 84.9% (95% CI, 75.8%-91.5%), with high heterogeneity ( test: <0.001; 2=83.63%). All studies reported toxicity data. Acute and late toxicity (grade ≥3) rates were 3.3%-18.0% and 6.0%-8.2%, respectively. Reported gastrointestinal side effects were duodenal obstruction/ulcer, small bowel obstruction, duodenal bleeding, hemorrhage, and gastric perforation. SBRT achieves pain relief in most patients with pancreatic cancer with an acceptable gastrointestinal toxicity rate. Further prospective studies are needed to define optimal dose/fractionation and the best systemic therapies modality integration to reduce toxicity and improve the palliative outcome. Finally, the quality of life and, particularly, pain control should be considered as an endpoint in all future trials on this emerging treatment technique.
PubMed: 30323651
DOI: 10.2147/JPR.S167994 -
World Journal of Gastroenterology Aug 2015To present a systematic review of techniques and clinical results. (Review)
Review
AIM
To present a systematic review of techniques and clinical results.
METHODS
A systematic review of published literature was performed. Only studies reporting patient outcome after radiosurgery (single fraction) delivered with robotic devices [i.e., robotic radiosurgery (RRS)] have been analyzed.
RESULTS
A total of 96 patients from 5 studies were included. The studies are characterized by small series and different methods in terms of dose, target definition, combination with chemotherapy and/or standard fractionated radiotherapy and evaluation modalities. Preliminary results are positive in terms of tumor response (ORR = 56%) and local control of the tumor (crude rate of local progressions: 19.5%). Results for median overall survival (11.4 mo) seem comparable with the ones of prolonged chemoradiation (range: 8.6-13.0 mo). However, gastrointestinal toxicity seems to be the main limitation of RRS, especially at the duodenal level.
CONCLUSION
RRS allows for local treatment in a shortened time (1 fraction) compared to traditional treatments (about 1 mo), providing the possibility for an easy integration with systemic therapies. Preliminary results did not show any outcome differences compared to standard chemoradiation. Thus, further efforts to reduce gastrointestinal toxicity are strongly needed.
Topics: Chemoradiotherapy; Dose Fractionation, Radiation; Humans; Pancreatic Neoplasms; Radiosurgery; Robotic Surgical Procedures; Treatment Outcome
PubMed: 26309369
DOI: 10.3748/wjg.v21.i31.9420 -
Clinical and Translational... Apr 2020Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited. (Comparative Study)
Comparative Study Meta-Analysis
INTRODUCTION
Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.
METHODS
A systematic literature search was performed to assess the feasibility and optimal method of double stenting for malignant duodenobiliary obstruction compared with surgical double bypass in terms of technical and clinical success, adverse events, reinterventions, and survival. Event rates with 95% confidence intervals were calculated.
RESULTS
Seventy-two retrospective and 8 prospective studies published until July 2018 were included. Technical and clinical success rates of double stenting were 97% (95%-99%) and 92% (89%-95%), respectively. Clinical success of endoscopic biliary stenting was higher than that of surgery (97% [94%-99%] vs 86% [78%-92%]). Double stenting was associated with less adverse events (13% [8%-19%] vs 28% [19%-38%]) but more frequent need for reintervention (21% [16%-27%] vs 10% [4%-19%]) than double bypass. No significant difference was found between technical and clinical success and reintervention rate of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage, and endoscopic ultrasound-guided biliary drainage. ERCP was associated with the least adverse events (3% [1%-6%]), followed by percutaneous transhepatic drainage (10% [0%-37%]) and endoscopic ultrasound-guided biliary drainage (23% [15%-33%]).
DISCUSSION
Substantially high technical and clinical success can be achieved with double stenting. Based on the adverse event profile, ERCP can be recommended as the first choice for biliary stenting as part of double stenting, if feasible. Prospective comparative studies with well-defined outcomes and cohorts are needed.
Topics: Bile Duct Neoplasms; Cholestasis; Drainage; Duodenal Neoplasms; Duodenal Obstruction; Endoscopy, Digestive System; Feasibility Studies; Humans; Neoplasm Invasiveness; Palliative Care; Pancreatic Neoplasms; Postoperative Complications; Reoperation; Stents; Stomach Neoplasms; Treatment Outcome
PubMed: 32352679
DOI: 10.14309/ctg.0000000000000161 -
Cancer Imaging : the Official... Oct 2017Malignant obstructive jaundice is a common problem in the clinic. Currently, the generally applied treatment methods are percutaneous transhepatic biliary drainage... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Malignant obstructive jaundice is a common problem in the clinic. Currently, the generally applied treatment methods are percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD). Nevertheless, there has not been a uniform conclusion published on either efficacy of the two types of drainage or the incidence rate of complications. Therefore, we conducted a systematic review and meta-analysis of studies comparing endoscopic versus percutaneous biliary drainage in malignant obstructive jaundice, to determine whether there is any difference between percutaneous and endoscopic biliary drainage, with respect to efficacy and incidence rate of overall complications.
METHODS
The enrolled studies contain a total of three randomized controlled trials and eleven retrospective studies, which together encompass 2246 patients with PTBD and 8100 patients with EBD.
RESULTS
Our analysis indicates that there is no difference between PTBD and EBD with regard to therapeutic success rate (%), overall complication (%), intraperitoneal bile leak, 30-day mortality, sepsis, or duodenal perforation (%). Cholangitis and pancreatitis after PTBD were lower than after EBD, with odds ratios (OR) of 0.48 (95% confidence interval (CI), 0.31 to 0.74) and 0.16 (95% CI, 0.05 to 0.52), respectively. Incidences of bleeding and tube dislocation for PTBD were higher than EBD, OR of 1.81 (95% CI, 1.35 to 2.44) and 3.41 (95% CI, 1.10 to 10.60).
CONCLUSIONS
This meta-analysis indicates certain advantages for both PTBD and EBD. In the clinical practice, it is advised to choose specifically either PTBD or EBD, based on location of obstruction, purpose of drainage (as a preoperative procedure or a palliative treatment) and level of experience in biliary drainage at individual treatment centers.
Topics: Bile Duct Neoplasms; Drainage; Endoscopy, Digestive System; Humans; Jaundice, Obstructive; Publication Bias; Retrospective Studies
PubMed: 29037223
DOI: 10.1186/s40644-017-0129-1 -
Clinics (Sao Paulo, Brazil) Jan 2016The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and... (Meta-Analysis)
Meta-Analysis Review
The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.
Topics: Adenoma; Ampulla of Vater; Common Bile Duct Neoplasms; Duodenal Neoplasms; Endoscopy; Humans; Pancreaticoduodenectomy; Recurrence; Treatment Outcome
PubMed: 26872081
DOI: 10.6061/clinics/2016(01)06 -
Journal of Clinical Medicine Mar 2024The optimal management of duodenal neuroendocrine neoplasms (dNENs) sized 10-20 mm remains controversial and although endoscopic resection is increasingly performed... (Review)
Review
The optimal management of duodenal neuroendocrine neoplasms (dNENs) sized 10-20 mm remains controversial and although endoscopic resection is increasingly performed instead of surgery, the therapeutic approach in this setting is not fully standardized. We performed a systematic review of the literature and a meta-analysis to clarify the outcomes of endoscopic resection for 10-20 mm dNENs in terms of efficacy (i.e., recurrence rate) and safety. A computerized literature search was performed using relevant keywords to identify pertinent articles published until January 2023. Seven retrospective studies were included in this systematic review. The overall recurrence rate was 14.6% (95%CI 5.4-27.4) in 65 patients analyzed, without significant heterogeneity. When considering studies specifically focused on endoscopic mucosal resection, the recurrence rate was 20.5% (95%CI 10.7-32.4), without significant heterogeneity. The ability to obtain the free margin after endoscopic resection ranged between 36% and 100%. No complications were observed in the four studies reporting this information. Endoscopic resection could be the first treatment option in patients with dNENs sized 10-20 mm and without evidence of metastatic disease. Further studies are needed to draw more solid conclusions, particularly in terms of superiority among the available endoscopic techniques.
PubMed: 38592317
DOI: 10.3390/jcm13051466 -
Endoscopy International Open May 2022Endoscopic submucosal dissection (ESD) is a standard method for minimally invasive resection of superficial gastrointestinal tumors. The pocket creation method (PCM)... (Review)
Review
Endoscopic submucosal dissection (ESD) is a standard method for minimally invasive resection of superficial gastrointestinal tumors. The pocket creation method (PCM) facilitates ESD regardless of location in the gastrointestinal tract. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of ESD for superficial neoplasms in the upper and lower gastrointestinal tract comparing the PCM to the non-PCM. Randomized controlled, prospective, and retrospective studies comparing the PCM with the non-PCM were included. Outcomes included en bloc resection, R0 resection, dissection speed, delayed bleeding and perforation. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) using the Mantel-Haenszel random effect model were documented. Eight studies including gastric, duodenal, and colorectal ESD were included. The en bloc resection rate was significantly higher in the PCM group than the non-PCM group (OR 3.87, 95 %CI 1.24-12.10 = 0.020). The R0 resection rate was significantly higher in the PCM group than the non-PCM group (OR 2.46, 95 %CI 1.14-5.30, = 0.020). The dissection speed was significantly faster in the PCM group than the non-PCM group (mean difference 3.13, 95 % CI 1.35-4.91, < 0.001). The rate of delayed bleeding was similar in the two groups (OR 1.13, 95 %CI 0.60-2.15, 0.700). The rate of perforation was significantly lower in the PCM group than the non-PCM group (OR 0.34, 95 %CI 0.15-0.76, 0.009). The PCM facilitates high-quality, fast and safe colorectal ESD. Further studies are needed regarding the utility of PCM in ESD of the upper gastrointestinal tract.
PubMed: 35571471
DOI: 10.1055/a-1789-0548 -
The Cochrane Database of Systematic... May 2018Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually occurs when malignancy is at an advanced stage; therefore, people have a limited life expectancy. It is of paramount importance to restore oral intake to improve quality of life for the person in a manner that has a minimal risk of complications and a short recovery period.
OBJECTIVES
To assess the benefits and harms of endoscopic stent placement versus surgical palliation for people with symptomatic malignant gastric outlet obstruction.
SEARCH METHODS
In May 2018 we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and Ovid CINAHL. We screened reference lists from included studies and review articles.
SELECTION CRITERIA
We included randomised controlled trials comparing stent placement with surgical palliation for people with gastric outlet obstruction secondary to malignant disease.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes, mean difference (MD) or standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where meaningful. We assessed the quality of evidence using GRADE criteria.
MAIN RESULTS
We identified three randomised controlled trials with 84 participants. Forty-one participants underwent surgical palliation and 43 participants underwent duodenal stent placement. There may have been little or no difference in the technical success of the procedure (RR 0.98, 95% CI 0.88 to 1.09; low-quality evidence), or whether the time to resumption of oral intake was quicker for participants who had undergone duodenal stent placement (MD -3.07 days, 95% CI -4.76 to -1.39; low-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved all-cause mortality and median survival postintervention.The time to recurrence of obstructive symptoms may have increased slightly following duodenal stenting (RR 5.08, 95% CI 0.96 to 26.74; moderate-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved serious and minor adverse events. The heterogeneity for adverse events was moderately high (serious adverse events: Chi² = 1.71; minor adverse events: Chi² = 3.08), reflecting the differences in definitions used and therefore, may have impacted the outcomes. The need for reintervention may have increased following duodenal stenting (RR 4.71, 95% CI 1.36 to 16.30; very low-quality evidence).The length of hospital stay may have been shorter (by approximately 4 to 10 days) following stenting (MD -6.70 days, 95% CI -9.41 to -3.98; moderate-quality evidence).
AUTHORS' CONCLUSIONS
The use of duodenal stent placement in malignant gastric outlet obstruction has the benefits of a quicker resumption of oral intake and a reduced inpatient hospital stay; however, this is balanced by an increase in the recurrence of symptoms and the need for further intervention.It is impossible to draw further conclusions on these and the other measured outcomes, primarily due to the low number of eligible studies and small number of participants which resulted in low-quality evidence. It was not possible to analyse the impact on quality of life each intervention had for these participants.
Topics: Adult; Duodenum; Eating; Gastric Outlet Obstruction; Gastrointestinal Neoplasms; Humans; Length of Stay; Palliative Care; Randomized Controlled Trials as Topic; Recurrence; Stents; Time Factors
PubMed: 29845610
DOI: 10.1002/14651858.CD012506.pub2 -
Nutrients Jun 2022Gastric cancer is a malignant neoplasm of the gastrointestinal tract, with one of the standard treatment methods remaining gastrectomy. The authors conducted a systemic... (Review)
Review
Gastric cancer is a malignant neoplasm of the gastrointestinal tract, with one of the standard treatment methods remaining gastrectomy. The authors conducted a systemic review of the Medline and Embase databases concerning the serum vitamin D level in post-gastrectomy gastric cancer patients, regarding all articles published until 22 May 2022 according to the PRISMA guidelines. 18 studies with a total number of 908 gastric cancer survivors were included in the analysis. The initial rate of vitamin D deficiency in gastric cancer patients undergoing gastrectomy appears to be similar to the global population deficiency. In post-gastrectomy survivors, the level of 25(OH)D may remain stable or decrease, while the level of 1, 25(OH)D remains normal. Supplementation with vitamin D results in an improvement in its serum concentration and positively affects bone mineral density, which is gradually reduced in post-gastrectomy survivors. Combining vitamin D supplementation with calcium and bisphosphonates enables us to obtain better results than vitamin D and calcium only. The type of surgery influences the level of serum vitamin D and its metabolites, with total or partial gastrectomy and maintenance of the duodenal food passage remaining the most important factors. There is a strong need for randomized, controlled trials that would investigate this matter in the future.
Topics: Calcium; Gastrectomy; Humans; Nutritional Status; Stomach Neoplasms; Vitamin D
PubMed: 35807892
DOI: 10.3390/nu14132712