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Medicine Jul 2022Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic review and meta-analysis to identify the risk factors of CR-POPF after PD.
METHODS
We searched PubMed, EMBASE, and Cochrane Library databases for studies related to risk factors of CR-POPF after PD. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were extracted from the included studies, then a meta-analysis was conducted. If necessary, sensitivity analysis would be performed by changing the effect model or excluding 1 study at a time. Publication bias was assessed by funnel plot and Begg test and Egger test.
RESULTS
A total of 27 studies with 24,740 patients were included, and CR-POPF occurred in 3843 patients (incidence = 17%, 95% CI: 16%-19%). Male (OR = 1.56, 95% CI: 1.42-1.70), body mass index >25 kg/m2 (OR = 1.98, 95% CI: 1.23-3.18), pancreatic duct diameter <3 mm (OR = 1.87, 95% CI: 1.66-2.12), soft pancreatic texture (OR = 3.49, 95% CI: 2.61-4.67), and blood transfusion (OR = 3.10, 95% CI: 2.01-4.77) can significantly increase the risk of CR-POPF. Pancreatic adenocarcinoma (OR = 0.54, 95% CI: 0.47-0.61), vascular resection (OR = 0.57, 95% CI: 0.39-0.83), and preoperative chemoradiotherapy (OR = 0.68, 95% CI: 0.57-0.81) can significantly decrease the factor of CR-POPF. Diabetes mellitus was not statistically associated with CR-POPF (OR = 0.66, 95% CI: 0.40-1.08). However, the analysis of body mass index, pancreatic texture, and diabetes mellitus had a high heterogeneity, then sensitivity analysis was performed, and the result after sensitivity analysis showed diabetes mellitus can significantly decrease the risk of CR-POPF. There was no significant publication bias in this meta-analysis.
CONCLUSIONS
The current review assessed the effects of different factors on CR-POPF. This can provide a basis for the prevention and management of CR-POPF. Effective interventions targeting the above risk factors should be investigated in future studies for decreasing the occurrence of CR-POPF.
Topics: Adenocarcinoma; Humans; Male; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 35776984
DOI: 10.1097/MD.0000000000029757 -
HPB : the Official Journal of the... Sep 2018Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs).
METHODS
A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model.
RESULTS
A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54).
CONCLUSION
The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Female; Humans; Incidence; Male; Middle Aged; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Randomized Controlled Trials as Topic; Risk Factors; Treatment Outcome; Young Adult
PubMed: 29773356
DOI: 10.1016/j.hpb.2018.03.003 -
Digestive Surgery 2016Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk... (Review)
Review
BACKGROUND/AIM
Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk factors often suffer subjective scaling. The aim of this review is to evaluate and compare all published risk metrics predictive of POPF.
METHODS
All existing scores were retrieved by literature web search. Inclusion criteria were ISGPF classification of POPF and the development of a risk score metric.
RESULTS
From a total of 286 publications, 10 studies were selected. Most of them were retrospective and single center. The models considered a median number of 3 items (range from 2 to 5); in 5 of 10 trials only pre or intraoperative variables were included. The median number of patients/study was 186 (IQR 111.1-229.0). External validation was performed in 6 of 10 studies. The most recurrent items were abdominal fat (4/10), main pancreatic duct diameter (in 4/10), and pancreatic texture (3/10).
CONCLUSION
POPF risk estimation should be easy, accurate, and objective. It should consider preoperative patient-related and gland-related features, and intraoperative events. None of the published systems completely adhere to these principles. Large heterogeneous multicentric validations should be endorsed, to account for the case-mix and evaluate the reproducibility of each scoring system.
Topics: Abdominal Fat; Humans; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Predictive Value of Tests; Risk Factors
PubMed: 27160158
DOI: 10.1159/000445068 -
In Vivo (Athens, Greece) 2020Malignant obstructive jaundice (MOJ) is a common condition caused by several primary and secondary cancers. We performed a systematic review and meta-analysis to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/AIM
Malignant obstructive jaundice (MOJ) is a common condition caused by several primary and secondary cancers. We performed a systematic review and meta-analysis to investigate technical success rate and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) in MOJ.
MATERIALS AND METHODS
Relevant trials were identified by searching electronic databases and conference meetings. We included thirteen retrospective studies and four randomized controlled trials, with PTBD performed in 2353 patients and EBD in 8178 patients. Outcomes of interest included: technical success rate, overall complications, 30-day mortality rate and risk of bleeding, pancreatitis, cholangitis and tube dislocation.
RESULTS
The differences in technical success rate, total complications, 30-day mortality rate and tube dislocation were not statistically significant between the two groups. Patients receiving PTBD showed a lower risk of pancreatitis (OR=0.14, 95%CI=0.06-0.31) and cholangitis (OR=0.52, 95%CI=0.30-0.90) when compared to EBD while PTBD was associated with higher risk of bleeding (OR=1.78; 95%CI=1.32-2.39).
CONCLUSION
Our meta-analysis indicates the presence of some advantages and limits for both PTBD and EBD. We highlight the paucity of quality-of-life data, a vital element which should be carefully pondered in future studies and in choosing the optimal technique in patients with MOJ.
Topics: Bile Duct Neoplasms; Drainage; Endoscopy; Humans; Jaundice, Obstructive; Retrospective Studies
PubMed: 32606139
DOI: 10.21873/invivo.11964 -
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 -
Cancers Apr 2024Clinical guidelines include monitoring blood test abnormalities to identify patients at increased risk of undiagnosed cancer. Noting blood test changes over time may... (Review)
Review
Clinical guidelines include monitoring blood test abnormalities to identify patients at increased risk of undiagnosed cancer. Noting blood test changes over time may improve cancer risk stratification by considering a patient's individual baseline and important changes within the normal range. We aimed to review the published literature to understand the association between blood test trends and undiagnosed cancer. MEDLINE and EMBASE were searched until 15 May 2023 for studies assessing the association between blood test trends and undiagnosed cancer. We used descriptive summaries and narratively synthesised studies. We included 29 articles. Common blood tests were haemoglobin (24%, n = 7), C-reactive protein (17%, n = 5), and fasting blood glucose (17%, n = 5), and common cancers were pancreatic (29%, n = 8) and colorectal (17%, n = 5). Of the 30 blood tests studied, an increasing trend in eight (27%) was associated with eight cancer types, and a decreasing trend in 17 (57%) with 10 cancer types. No association was reported between trends in 11 (37%) tests and breast, bile duct, glioma, haematological combined, liver, prostate, or thyroid cancers. Our review highlights trends in blood tests that could facilitate the identification of individuals at increased risk of undiagnosed cancer. For most possible combinations of tests and cancers, there was limited or no evidence.
PubMed: 38730644
DOI: 10.3390/cancers16091692 -
Canadian Journal of Gastroenterology &... 2022While endoscopic retrograde cholangiopancreatography (ERCP) is a valuable diagnostic and therapeutic tool in primary sclerosing cholangitis (PSC), there is conflicting... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
While endoscopic retrograde cholangiopancreatography (ERCP) is a valuable diagnostic and therapeutic tool in primary sclerosing cholangitis (PSC), there is conflicting data on associated adverse events. The aims of this systematic review and meta-analysis are to (1) compare ERCP-related adverse events in patients with and without PSC and (2) determine risk factors for ERCP-related adverse events in PSC.
METHODS
Embase, PubMed, and CENTRAL were searched between January 1, 2000, and May 12, 2021. Eligible studies included adults with PSC undergoing ERCP and reported at least one ERCP-related adverse event (cholangitis, pancreatitis, bleeding, and perforation) or an associated risk factor. The risk of bias was assessed with the Newcastle-Ottawa scale and Cochrane Risk of Bias 2. Raw event rates were used to calculate odds ratios (ORs) and then pooled using random-effects models.
RESULTS
Twenty studies met eligibility criteria, of which four were included in a meta-analysis comparing post-ERCP adverse events in patients with PSC ( = 715) to those without PSC ( = 9979). We found a significant threefold increase in the 30-day odds of cholangitis in PSC compared to those without (OR 3.263, 95% CI 1.076-9.896; =0.037). However, there were no significant differences in post-ERCP pancreatitis (PEP), bleeding, or perforation. Due to limitations in primary data, only risk factors contributing to PEP could be analyzed. Accidental passage of the guidewire into the pancreatic duct (OR 7.444, 95% CI 3.328-16.651; < 0.001; = 65.0%) and biliary sphincterotomy (OR 4.802, 95% CI 1.916-12.033; =0.001; = 73.1%) were associated with higher odds of PEP in a second meta-analysis including five studies.
CONCLUSIONS
In the context of limited comparative data and heterogeneity, PSC patients undergoing ERCP have higher odds of cholangitis despite the majority receiving antibiotics. Additionally, accidental wire passage and biliary sphincterotomy increased the odds of PEP. Future studies on ERCP-related risks and preventive strategies are needed.
Topics: Adult; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Cholangitis; Cholangitis, Sclerosing; Humans; Pancreatitis
PubMed: 35910039
DOI: 10.1155/2022/2372257 -
Gastroenterology Report Apr 2021Abdominal pain is a debilitating symptom affecting ∼80% of pancreatic cancer (PC) patients. Pancreatic duct (PD) decompression has been reported to alleviate this...
BACKGROUND
Abdominal pain is a debilitating symptom affecting ∼80% of pancreatic cancer (PC) patients. Pancreatic duct (PD) decompression has been reported to alleviate this pain, although this practice has not been widely adopted. We aimed to evaluate the role, efficacy, and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.
METHODS
A systematic review until 7 October 2020 was performed. Two independent reviewers selected studies, extracted data, and assessed the methodological quality.
RESULTS
We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain, in whom PD decompression was attempted, and was successful in 167 patients (mean age 62.5 years, 58.7% males). The use of plastic stents was reported in 159 patients (95.2%). All included studies reported partial or complete improvement in pain levels after PD stenting, with an improvement rate of 93% (95% confidence interval, 79%-100%). The mean duration of pain improvement was 94 ± 16 days. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) were post-sphincterotomy bleeding (1.8%), post-ERCP pancreatitis (0.6%), and hemosuccus pancreaticus (0.6%). AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression. In the 167 patients with technical success, the stent-migration and stent-occlusion rates were 3.6% and 3.0%, respectively. No AE-related mortality was reported. The methodological quality assessment showed the majority of the studies having low or unclear quality.
CONCLUSION
In this exploratory analysis, endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain. However, a randomized-controlled trial is needed to delineate the role of this invasive practice.
PubMed: 34026217
DOI: 10.1093/gastro/goab001 -
Digestive Diseases and Sciences May 2021Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not...
BACKGROUND
Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis.
METHODS
A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted.
RESULTS
We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP.
CONCLUSIONS
This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.
Topics: Amylases; Biomarkers; Cholangiopancreatography, Endoscopic Retrograde; Cholangiopancreatography, Magnetic Resonance; Clinical Enzyme Tests; Endosonography; Humans; Pancreatic Ducts; Pancreatitis; Predictive Value of Tests; Reproducibility of Results; Secretin; Severity of Illness Index
PubMed: 32594462
DOI: 10.1007/s10620-020-06413-0 -
The Cochrane Database of Systematic... May 2016Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review.
OBJECTIVES
To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers.
SELECTION CRITERIA
Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/).
MAIN RESULTS
We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice.
AUTHORS' CONCLUSIONS
This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.
Topics: Hospital Mortality; Humans; Pancreatic Fistula; Pancreaticoduodenectomy; Randomized Controlled Trials as Topic; Reoperation; Stents; Time Factors; Treatment Outcome
PubMed: 27153248
DOI: 10.1002/14651858.CD008914.pub3