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The Journal of Spinal Cord Medicine Jul 2023Spinal cord injury (SCI) is associated with several gastrointestinal disorders, and the prevalence of cholelithiasis is high in this population. Because individuals with...
CONTEXT
Spinal cord injury (SCI) is associated with several gastrointestinal disorders, and the prevalence of cholelithiasis is high in this population. Because individuals with SCI may have atypical symptoms and more advanced disease, some treatment centers advocate prophylactic cholecystectomy for patients with SCI and gallstone disease.
OBJECTIVE
To systematically review the existence and quality of studies on prophylactic cholecystectomy in individuals with SCI and cholelithiasis.
METHODS
A systematic search of literature up to July 10, 2022 was conducted in accordance with PRISMA guidelines using the Medline, Cochrane, and Web of Science databases. Keywords used were "cholecystectomy," "gallbladder," "cholelithiasis," "gallstone," and "spinal cord injury."
RESULTS
The search identified 118 articles, of which 4 met the inclusion criteria. All these were retrospective observational studies. Prophylactic cholecystectomy was performed in 4-16.5% of the participants. The causes of cholecystectomy were chronic cholecystitis with biliary colic (44.5-63.5%), acute cholecystitis (4-26%), choledocholithiasis (6-11%) and pancreatitis (2-6%). Operative times, conversion rates, estimated blood loss, severity of complications, morbidity and mortality did not differ significantly between individuals with SCI and neurologically able individuals.
CONCLUSION
No prospective cohort studies comparing prophylactic cholecystectomy with conservative management in individuals with SCI and gallstone disease have been conducted. Therefore, there is no robust evidence to support prophylactic cholecystectomy and further studies are required.
Topics: Humans; Spinal Cord Injuries; Retrospective Studies; Cholecystectomy; Cholelithiasis
PubMed: 36355833
DOI: 10.1080/10790268.2022.2144026 -
The Cochrane Database of Systematic... Nov 2019Sickle cell disease (SCD) is a group of inherited disorders of haemoglobin (Hb) structure in a person who has inherited two mutant globin genes (one from each parent),... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sickle cell disease (SCD) is a group of inherited disorders of haemoglobin (Hb) structure in a person who has inherited two mutant globin genes (one from each parent), at least one of which is always the sickle mutation. It is estimated that between 5% and 7% of the world's population are carriers of the mutant Hb gene, and SCD is the most commonly inherited blood disorder. SCD is characterized by distorted sickle-shaped red blood cells. Manifestations of the disease are attributed to either haemolysis (premature red cell destruction) or vaso-occlusion (obstruction of blood flow, the most common manifestation). Shortened lifespans are attributable to serious comorbidities associated with the disease, including renal failure, acute cholecystitis, pulmonary hypertension, aplastic crisis, pulmonary embolus, stroke, acute chest syndrome, and sepsis. Vaso-occlusion can lead to an acute, painful crisis (sickle cell crisis, vaso-occlusive crisis (VOC) or vaso-occlusive episode). Pain is most often reported in the joints, extremities, back or chest, but it can occur anywhere and can last for several days or weeks. The bone and muscle pain experienced during a sickle cell crisis is both acute and recurrent. Key pharmacological treatments for VOC include opioid analgesics, non-opioid analgesics, and combinations of drugs. Non-pharmacological approaches, such as relaxation, hypnosis, heat, ice and acupuncture, have been used in conjunction to rehydrating the patient and reduce the sickling process.
OBJECTIVES
To assess the analgesic efficacy and adverse events of pharmacological interventions to treat acute painful sickle cell vaso-occlusive crises in adults, in any setting.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online, MEDLINE via Ovid, Embase via Ovid and LILACS, from inception to September 2019. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries.
SELECTION CRITERIA
Randomized, controlled, double-blind trials of pharmacological interventions, of any dose and by any route, compared to placebo or any active comparator, for the treatment (not prevention) of painful sickle cell VOC in adults.
DATA COLLECTION AND ANALYSIS
Three review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio (RR) and number needed to treat for one additional event, using standard methods. Our primary outcomes were participant-reported pain relief of 50%, or 30%, or greater; Patient Global Impression of Change (PGIC) very much improved, or much or very much improved. Our secondary outcomes included adverse events, serious adverse events, and withdrawals due to adverse events. We assessed GRADE and created three 'Summary of findings' tables.
MAIN RESULTS
We included nine studies with data for 638 VOC events and 594 participants aged 17 to 42 years with SCD presenting to a hospital emergency department in a painful VOC. Three studies investigated a non-steroidal anti-inflammatory drug (NSAID) compared to placebo. One study compared an opioid with a placebo, two studies compared an opioid with an active comparator, two studies compared an anticoagulant with a placebo, and one study compared a combination of three drugs with a combination of four drugs. Risk of bias across the nine studies varied. Studies were primarily at an unclear risk of selection, performance, and detection bias. Studies were primarily at a high risk of bias for size with fewer than 50 participants per treatment arm; two studies had 50 to 199 participants per treatment arm (unclear risk). Non-steroidal anti-inflammatory drugs (NSAID) compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The efficacy was uncertain regarding PGIC very much improved, and PGIC much or very much improved (no difference; 1 study, 21 participants; very low-quality evidence). Very low-quality, uncertain results suggested similar rates of adverse events across both the NSAIDs group (16/45 adverse events, 1/56 serious adverse events, and 1/56 withdrawal due to adverse events) and the placebo group (19/45 adverse events, 2/56 serious adverse events, and 1/56 withdrawal due to adverse events). Opioids compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30%, PGIC, or adverse events (any adverse event, serious adverse events, and withdrawals due to adverse events). Opioids compared with active comparator No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The results were uncertain regarding PGIC very much improved (33% of the opioids group versus 19% of the placebo group). No data were reported regarding PGIC much or very much improved. Very low-quality, uncertain results suggested similar rates of adverse events across both the opioids group (9/66 adverse events, and 0/66 serious adverse events) and the placebo group (7/64 adverse events, 0/66 serious adverse events). No data were reported regarding withdrawal due to adverse events. Quality of the evidence We downgraded the quality of the evidence by three levels to very low-quality because there are too few data to have confidence in results (e.g. too few participants per treatment arm). Where no data were reported for an outcome, we had no evidence to support or refute (quality of the evidence is unknown).
AUTHORS' CONCLUSIONS
This review identified only nine studies, with insufficient data for all pharmacological interventions for analysis. The available evidence is very uncertain regarding the efficacy or harm from pharmacological interventions used to treat pain related to sickle cell VOC in adults. This area could benefit most from more high quality, certain evidence, as well as the establishment of suitable registries which record interventions and outcomes for this group of people.
Topics: Acute Pain; Analgesics; Analgesics, Opioid; Anemia, Sickle Cell; Anti-Inflammatory Agents, Non-Steroidal; Humans; Pain Management; Pain Measurement; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic
PubMed: 31742673
DOI: 10.1002/14651858.CD012187.pub2 -
Medicine Nov 2022With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP... (Meta-Analysis)
Meta-Analysis
Is early laparoscopic cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography superior?: A systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP might induce complications including pancreatitis and cholecystitis that could affect a subsequent laparoscopic cholecystectomy (LC), leading to conversion to open cholecystectomy perioperative complications. It is not yet known whether or not the time interval between ERCP and LC plays a role in increasing conversion rate and complications. Bides, in the traditional sense, after ERCP, for avoiding edema performing LC was several weeks later. Even no one study could definite whether early laparoscopic cholecystectomy after ERCP affected the prognosis or not clearly.
OBJECTIVE
Comparing some different surgical timings of LC after ERCP.
METHOD
Searching databases consist of all kinds of searching tools, such as Medline, Cochrane Library, Embase, PubMed, etc. All the included studies should meet the demands of this meta-analysis. In all interest outcomes below, we took full advantage of RevMan5 and WinBUGS to assess; the main measure was odds ratio (OR) with 95% confidence. Moreover, considering the inconsistency of the specific time points in different studies, we set a subgroup to analyze the timing of LC after ERCP. For this part, Bayesian network meta-analysis was done with WinBUGS.
RESULT
In the pool of conversion rate, the result suggested that the early LC group was equal compared with late LC (OR = 0.68, I2 = 0%, P = .23). Besides, regarding morbidity, there was no significant difference between the 2 groups (OR = 0.74, I2 = 0%, P = .26). However, early LC, especially for laparoscopic-endoscopic rendezvous that belonged to performing LC within 24 hours could reduce the post-ERCP pancreatitis (OR = 0.16, I2 = 29%, P = .0003). Considering early LC included a wide time and was not precise enough, we set a subgroup by Bayesian network, and the result suggested that performing LC during 24 to 72 hours was the lowest conversion rate (rank 1: 0%).
CONCLUSION
In the present study, LC within 24 to 72 hours conferred advantages in terms of the conversion rate, with no recurrence of acute cholecystitis episodes.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy, Laparoscopic; Bayes Theorem; Randomized Controlled Trials as Topic; Gallstones; Pancreatitis; Common Bile Duct
PubMed: 36397448
DOI: 10.1097/MD.0000000000031365 -
Canadian Journal of Surgery. Journal... Aug 2019Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers...
BACKGROUND
Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model.
METHODS
We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate.
RESULTS
The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied.
CONCLUSION
Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.
Topics: Appendicitis; Cholecystitis; Emergency Medical Services; Emergency Service, Hospital; General Surgery; Humans; Length of Stay; Patient Care Team; Postoperative Complications; Surgical Procedures, Operative; Time-to-Treatment; Treatment Outcome
PubMed: 31148441
DOI: 10.1503/cjs.010718