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European Journal of Radiology Oct 2023The growing application of deep learning in radiology has raised concerns about cybersecurity, particularly in relation to adversarial attacks. This study aims to... (Review)
Review
PURPOSE
The growing application of deep learning in radiology has raised concerns about cybersecurity, particularly in relation to adversarial attacks. This study aims to systematically review the literature on adversarial attacks in radiology.
METHODS
We searched for studies on adversarial attacks in radiology published up to April 2023, using MEDLINE and Google Scholar databases.
RESULTS
A total of 22 studies published between March 2018 and April 2023 were included, primarily focused on image classification algorithms. Fourteen studies evaluated white-box attacks, three assessed black-box attacks and five investigated both. Eleven of the 22 studies targeted chest X-ray classification algorithms, while others involved chest CT (6/22), brain MRI (4/22), mammography (2/22), abdominal CT (1/22), hepatic US (1/22), and thyroid US (1/22). Some attacks proved highly effective, reducing the AUC of algorithm performance to 0 and achieving success rates up to 100 %.
CONCLUSIONS
Adversarial attacks are a growing concern. Although currently the threats are more theoretical than practical, they still represent a potential risk. It is important to be alert to such attacks, reinforce cybersecurity measures, and influence the formulation of ethical and legal guidelines. This will ensure the safe use of deep learning technology in medicine.
Topics: Humans; Radiography; Radiology; Mammography; Tomography, X-Ray Computed; Algorithms
PubMed: 37699278
DOI: 10.1016/j.ejrad.2023.111085 -
Gastrointestinal Endoscopy Sep 2023Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes.
METHODS
We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).
RESULTS
Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates.
CONCLUSIONS
HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Pancreatitis; Cholangitis
PubMed: 37201726
DOI: 10.1016/j.gie.2023.05.045 -
Gastrointestinal Endoscopy Oct 2023Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.
METHODS
A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.
RESULTS
One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I = 77.5%).
CONCLUSIONS
Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.
Topics: Humans; Cholestasis; Endosonography; Cholangitis; Drainage; Stents; Cholangiopancreatography, Endoscopic Retrograde
PubMed: 37392952
DOI: 10.1016/j.gie.2023.06.055 -
Surgical Endoscopy Dec 2023Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD.
METHODS
The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest.
RESULTS
Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity.
CONCLUSION
ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.
Topics: Humans; Female; Male; Sphincterotomy, Endoscopic; Sphincter of Oddi Dysfunction; Sphincter of Oddi; Cholangiopancreatography, Endoscopic Retrograde; Manometry; Abdominal Pain
PubMed: 37964092
DOI: 10.1007/s00464-023-10539-3 -
Asian Journal of Surgery Oct 2023Bile leak is a rare complication after Laparoscopic Cholecystectomy. Subvesical bile duct (SVBD) injury is the second cause of minor bile leak, following the... (Review)
Review
Bile leak is a rare complication after Laparoscopic Cholecystectomy. Subvesical bile duct (SVBD) injury is the second cause of minor bile leak, following the unsuccessful clipping of the cystic duct stump. The aim of this study is to pool available data on this type of biliary tree anatomical variation to summarize incidence of injury, methods used to diagnose and treat SVBD leaks after LC. Articles published between 1985 and 2021 describing SVBD evidence in patients operated on LC for gallstone disease, were included. Data were divided into two groups based on the intra or post-operative evidence of bile leak from SVBD after surgery. This systematic report includes 68 articles for a total of 231 patients. A total of 195 patients with symptomatic postoperative bile leak are included in Group 1, while Group 2 includes 36 patients describing SVBD visualized and managed during LC. Outcomes of interest were diagnosis, clinical presentation, treatment, and outcomes. The management of minor bile leak is controversial. In most of cases diagnosed postoperatevely, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is the best way to treat this complication. Surgery should be considered when endoscopic or radiological approaches are not resolutive.
Topics: Humans; Cholecystectomy, Laparoscopic; Postoperative Complications; Cholangiopancreatography, Endoscopic Retrograde; Bile Ducts; Bile Duct Diseases; Biliary Tract Diseases
PubMed: 37127504
DOI: 10.1016/j.asjsur.2023.04.031 -
Surgical Endoscopy Sep 2023Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP)... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP) intervention. Laparoscopically Assisted Transgastric ERCP (LA-ERCP) has emerged to address the issue of accessing the excluded stomach. This study aims to evaluate the safety and efficacy of LA-ERCP procedure following RYGB.
METHODS
The Cochrane, EMBASE, SCOPUS, MEDLINE, Daily and Epub databases were searched from inception to May 2022 using the PRISMA guidelines. Eligible studies reported participants older than 18 years who underwent the LA-ERCP procedure, following RYGB, and outcomes of patients.
RESULTS
27 unique studies met the inclusion criteria with 1283 patients undergoing 1303 LA-ERCP procedures. 81.9% of the patients were female and the mean age was 52.18 ± 13.38 years. The rate of concurrent cholecystectomy was 33.6%. 90.9% of procedures were undertaken for a biliary indication. The mean time between RYGB and LA-ERCP was 89.19 months. The most common intervention performed during the LA-ERCP was a sphincterotomy (94.3%). Mean total operative time was 130.48 min. Mean hospital length of stay was 2.697 days. Technical success was 95.3%, while clinical success was 93.8%. 294 complications were recorded with a 20.6% complication rate. The most frequent complications encountered were pancreatitis (6.8%), infection (6.1%), bleeding (3.4%), and perforation (2.5%). Rate of conversion to open laparotomy was 7%.
CONCLUSION
This meta-analysis presents preliminary evidence to suggest the safety and efficacy of LA-ERCP procedure following RYGB. Further investigations are warranted to evaluate the long-term efficacy of this procedure using studies with long-term patient follow-up.
Topics: Humans; Female; Adult; Middle Aged; Aged; Male; Cholangiopancreatography, Endoscopic Retrograde; Gastric Bypass; Cholecystectomy; Databases, Factual; Hospitals
PubMed: 37479839
DOI: 10.1007/s00464-023-10276-7 -
Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis.American Journal of Surgery Mar 2024With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders.
METHODS
Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality.
RESULTS
Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 % vs. 1.6 %, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47).
CONCLUSION
SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.
Topics: Humans; Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis; Reoperation; Cholangiopancreatography, Endoscopic Retrograde
PubMed: 38168604
DOI: 10.1016/j.amjsurg.2023.12.022 -
Medicine Oct 2023To evaluate the efficacy of nafamostat mesilate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) by conduct a systematic... (Meta-Analysis)
Meta-Analysis
Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis based on prospective, randomized, and controlled trials.
OBJECTIVES
To evaluate the efficacy of nafamostat mesilate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) by conduct a systematic review and meta-analysis.
METHOD
We retrieved for all randomized controlled trials (RCTs) about compare nafamostat mesilate with placebo in preventing PEP published before August 23, 2022, in 5 major electronic databases. The primary outcome was PEP rate, and the secondary outcome was post-ERCP hyperamylasemia (PEHA) rate. Subgroup analyses were performed to reveal the factors that may affect the preventive effect of nafamostat. Assessment of the quality of evidence was conducted based on Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system.
RESULTS
According to the search strategy and criteria of inclusion and exclusion, 8 articles with a number of 3210 patients were included. The PEP incidence of the nafamostat group was inferior compared with the placebo group (4.6% vs 8.5%, RR = 0.50, 95% CI: 0.38-0.66). Subgroup analyses revealed that nafamostat had a preventive effect on patients with different risk stratification (High-risk: RR = 0.61, 95% CI: 0.43-0.86, Low-risk: RR = 0.28; 95% CI: 0.17-0.47). Different doses (20 mg: RR = 0.50, 95% CI: 0.36-0.69, 50 mg: RR = 0.45, 95% CI: 0.27-0.74) and duration (<12 hour: RR = 0.55, 95% CI: 0.37-0.81, ≥12 h: RR = 0.44, 95% CI: 0.29-0.66) of administration of nafamostat are adequate for the prevention of PEP, but postoperative administration may not help (preoperative: RR = 0.52, 95% CI: 0.39-0.69, postoperative: RR = 0.54, 95% CI: 0.23-1.23). Nafamostat may not efficacious in preventing severe PEP (Mild: RR = 0.49, 95% CI, 0.35-0.68, Moderate: RR = 0.47, 95% CI: 0.25-0.86, Severe: RR = 0.91, 95% CI, 0.25-3.29) or in low-quality studies (Low-quality: RR = 0.69, 95% CI: 0.13-3.60, High-quality: RR = 0.49, 95% CI: 0.37-0.65).
CONCLUSION
Preoperative use of nafamostat can effectively prevent PEP in patients with various risk stratification. Nafamostat can prevent mild and moderate PEP, but may not prevent severe PEP and PEHA. There should be more high-quality RCTs in future to strengthen the evidence of nafamostat in preventing PEP.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Pancreatitis; Guanidines; Benzamidines; Hyperamylasemia; Randomized Controlled Trials as Topic
PubMed: 37832051
DOI: 10.1097/MD.0000000000035174 -
Pancreatology : Official Journal of the... Feb 2024Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While previous systematic reviews have shown NSAIDs reduce PEP, their impact on moderate to severe PEP (MSPEP) is unclear. We conducted a systematic review and meta-analysis to understand the impact of NSAIDs on MSPEP among patients who developed PEP. We later surveyed physicians' understanding of that impact.
DESIGN
A systematic search for randomized trials using NSAIDs for PEP prevention was conducted. Pooled-prevalence and Odds-ratio of PEP, MSPEP were compared between treated vs. control groups. Analysis was performed using R software. Random-effects model was used for all variables. Physicians were surveyed via email before and after reviewing our results.
RESULTS
7688 patients in 25 trials were included. PEP was significantly reduced to 0.598 (95%CI, 0.47-0.76) in the NSAIDs group. Overall burden of MSPEP was reduced among all patients undergoing ERCP: OR 0.59 (95%CI, 0.42-0.83). However, NSAIDs didn't affect the proportion of MSPEP among those who developed PEP (p = 0.658). Rectal Indomethacin and diclofenac reduced PEP but not MSPEP. Efficacy didn't vary by risk, timing of administration, or bias-risk. Survey revealed a change in the impression of the effect of NSAIDs on MSPEP after reviewing our results.
CONCLUSIONS
Rectal diclofenac or indomethacin before or after ERCP reduce the overall burden of MSPEP by reducing the pool of PEP from which it can arise. However, the proportion of MSPEP among patients who developed PEP is unaffected. Therefore, NSAIDs prevent initiation of PEP, but do not affect severity among those that develop PEP. Alternative modalities are needed to reduce MSPEP among patients who develop PEP.
Topics: Humans; Diclofenac; Cholangiopancreatography, Endoscopic Retrograde; Administration, Rectal; Anti-Inflammatory Agents, Non-Steroidal; Indomethacin; Pancreatitis
PubMed: 37981523
DOI: 10.1016/j.pan.2023.11.003 -
Annals of Surgical Oncology Feb 2024Optimal preoperative biliary drainage for patients with pancreatic cancer before pancreatoduodenectomy remains unclear. This study aimed to investigate the comparison of... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Optimal preoperative biliary drainage for patients with pancreatic cancer before pancreatoduodenectomy remains unclear. This study aimed to investigate the comparison of efficacy and safety between a metallic stent (MS) and a plastic stent (PS).
METHODS
Comparative studies on the use of MS and PS for pancreatic cancer before pancreatoduodenectomy were systematically searched using the MEDLINE and Web of Science databases. Pre- and postoperative data also were extracted. Random-effects meta-analyses were performed to compare post-endoscopic retrograde cholangiopancreatography (ERCP) complications as well as intra- and postoperative outcomes between the two arms of the study, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 percent confidence intervals (CIs).
RESULTS
The study analyzed 12 studies involving 683 patients. Insertion of MS was associated with a lower incidence of re-intervention (OR, 0.06; 95% CI 0.03-0.15; P < 0.001), increased post-ERCP adverse events (OR, 2.22; 95% CI 1.13-4.36; P = 0.02), and similar operation time (MD, 18.0 min; 95% CI -29.1 to 65.6 min; P = 0.46), amount of blood loss (MD, 43.0 ml; 95% CI -207.1 to 288.2 ml; P = 0.73), and surgical complication rate (OR, 0.78; 95% CI 0.53-1.15; P = 0.21). The cumulative stent patency rate after 3 months was higher in the MS group than in the PS group (70-100 % vs 30.0-45.0 %).
CONCLUSION
For biliary drainage in patients with pancreatic cancer during this era of multidisciplinary treatment, MS use might be the first choice because MS provides a more durable biliary drainage and a similar risk of postoperative outcomes compared with PS.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cholestasis; Drainage; Pancreas; Pancreatic Neoplasms; Stents; Treatment Outcome
PubMed: 37952017
DOI: 10.1245/s10434-023-14523-y