-
Annals of Gastroenterology 2021The American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF),...
BACKGROUND
The American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF), whereas the American College of Gastroenterology recommends EUS for ≥1 HRF. This systematic review and meta-analysis compared the diagnostic accuracy of using ≥1 vs. ≥2 HRF for assessing the risk of advanced neoplasia (AN) and performing EUS in PCL.
METHODS
An electronic database search was performed for eligible studies. AN was defined as pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm or mucinous cystadenoma with high-grade dysplasia, pancreatic intraepithelial neoplasia and pancreatic neuroendocrine tumors. HRF included cyst size ≥3 cm, solid component, and dilated pancreatic duct ≥5 mm. The primary outcome was the sensitivity and specificity of using ≥1 vs. ≥2 HRF as an indication for EUS to detect AN in PCL.
RESULTS
Of 38 studies initially screened, 8 were included in the final analysis. Seven studies assessed the accuracy of ≥2 HRF and 4 studies assessed ≥1 HRF. The pooled sensitivity, specificity, positive and negative predictive values of EUS for detecting AN were 41.7% (95% confidence interval 19.5-67.8%), 90.8% (81.9-95.5%), 30.4% (19.4-44.2%) and 94.3% (89.6-97.0%) with ≥2HRFs, and 77.1% (66.1-85.3%), 72.7% (50.4-87.5%), 17.95% (10.3-29.4%), 98.1% (90.8-99.6%), respectively, with ≥1 HRF.
CONCLUSION
Performing EUS for PCL with ≥1 HRF could offer greater sensitivity in detecting AN compared to ≥2 HRF, with a similar negative predictive value.
PubMed: 34475747
DOI: 10.20524/aog.2021.0630 -
Endoscopy International Open Nov 2020Endoscopic ultrasound guided pancreatic duct drainage (EUS-PDD) is a minimal-invasive therapeutic option to surgery and in patients with failed endoscopic retrograde...
Endoscopic ultrasound guided pancreatic duct drainage (EUS-PDD) is a minimal-invasive therapeutic option to surgery and in patients with failed endoscopic retrograde pancreatography (ERP). The aim of this review was to quantitatively appraise the clinical outcomes of EUS-PDD by meta-analysis methods. We searched multiple databases from inception through March 2020 to identify studies that reported on EUS-PDD. Pooled rates of technical success, successful drainage of pancreatic duct, clinical success, and adverse events were calculated. Study heterogeneity was assessed using I % and 95 % prediction interval. A total of 22 studies (714 patients) were included. The pooled rate of technical success in EUS-PDD was 84.8 % (95 % CI 79.1-89.2). The pooled rate of successful PD drained by EUS-PDD was 77.5 % (95 % CI 63.1-87.4). The pooled rate of clinical success of EUS-PDD was 89.2 % (95 % CI 82.1-93.7). The pooled rate of all adverse events was 18.1 % (95 % CI 14.2-22.9). On sub-group analysis, the pooled technical success and clinical success of EUS-PDD from Japanese data were considerably superior (91.2 %, 83-95.6 & 92.5 %, 83.9-96.7, respectively). The pooled rate of post EUS-PDD acute pancreatitis was 6.6 % (95 % CI 4.5-9.4), bleeding was 4.1 % (95 % CI 2.7-6.2), perforation and/or pneumoperitoneum was 3.1 % (95 % CI 1.9-5), pancreatic leak and/or pancreatic fluid collection was 2.3 % (95 % CI 1.4-4), and infection was 2.8 % (95 % CI 1.7-4.6). EUS-PDD demonstrates high technical success and clinical success rates with acceptable adverse events. Technical success was especially high for anastomotic strictures.
PubMed: 33140022
DOI: 10.1055/a-1236-3350 -
Frontiers in Oncology 2021To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic open pancreaticoduodenectomy (LPD OPD), we performed a...
BACKGROUND
To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic open pancreaticoduodenectomy (LPD OPD), we performed a meta-analysis of currently available propensity score matching studies and large-scale retrospective cohorts to compare the safety and overall effect of LPD to OPD for patients with PDAC.
METHODS
A meta-analysis was registered at PROSPERO and the registration number is CRD42021250395. PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Data on operative times, blood loss, 30-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥3 complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, overall survival, and long-term survival) were subjected to meta-analysis.
RESULTS
Overall, we identified 10 retrospective studies enrolling a total of 11,535 patients (1,514 and 10,021 patients underwent LPD and OPD, respectively). The present meta-analysis showed that there were no significant differences in overall survival time, 1-year survival, 2-year survival, 30-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, and lymph node dissection between the LPD and OPD groups. Nevertheless, compared with the OPD group, LPD resulted in significantly higher rate of R0 resection (OR: 1.22; 95% CI 1.06-1.40; = 0.005), longer operative time (WMD: 60.01 min; 95% CI 23.23-96.79; = 0.001), lower Clavien-Dindo grade ≥III rate ( = 0.02), less blood loss (WMD: -96.49 ml; 95% CI -165.14 to -27.83; = 0.006), lower overall morbidity rate (OR: 0.65; 95% CI 0.50 to 0.85; = 0.002), shorter LOS (MD = -2.73; 95% CI -4.44 to -1.03; = 0.002), higher 4-year survival time ( = 0.04), 5-year survival time ( = 0.001), and earlier time to starting adjuvant chemotherapy after surgery (OR: -10.86; 95% CI -19.42 to -2.30; = 0.01).
CONCLUSIONS
LPD is a safe and feasible alternative to OPD for patients with PDAC, and compared with OPD, LPD seemed to provide a similar OS.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/PROSPERO/#recordDetails.
PubMed: 34778064
DOI: 10.3389/fonc.2021.749140 -
Life (Basel, Switzerland) Aug 2023This systematic review analyzes the anatomical variants in the pancreas and its ductal system to report on their association with pancreatic pathologies. (Review)
Review
OBJECTIVE
This systematic review analyzes the anatomical variants in the pancreas and its ductal system to report on their association with pancreatic pathologies.
METHODS
We conducted a search of the MEDLINE, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception to July 2023. The methodological quality was assessed with the Anatomical Quality Assessment (AQUA) tool. Finally, the pooled prevalence was estimated using a random effects model.
RESULTS
55 studies were found that met the eligibility criteria. The overall prevalence of pancreas divisum (PD) was 18% (95% CI = 15-21%). The prevalence of PD associated with pancreatitis was 30% (95% CI = 1-61%).
CONCLUSIONS
An anatomical variant of the pancreas such as PD may be the cause of bile duct obstruction, resulting in various clinical complications, such as pancreatitis. Hence, knowing this variant is extremely important for surgeons, especially for those who treat the gastroduodenal region.
PubMed: 37629567
DOI: 10.3390/life13081710 -
HPB : the Official Journal of the... Dec 2019The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy).
METHODS
A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases.
RESULTS
Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD -115.8 min, CI -142.2 to -89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection.
CONCLUSION
EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.
Topics: Exocrine Pancreatic Insufficiency; Gastric Emptying; Humans; Length of Stay; Neoplasm Recurrence, Local; Operative Time; Pancreatectomy; Pancreatic Fistula; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Postoperative Hemorrhage
PubMed: 31153837
DOI: 10.1016/j.hpb.2019.04.015 -
Archives of Osteoporosis Feb 2022Osteopenia typically presents low bone mineral density (BMD) and has recently been reported as a prognostic factor in various cancers. However, the prognostic value of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Osteopenia typically presents low bone mineral density (BMD) and has recently been reported as a prognostic factor in various cancers. However, the prognostic value of osteopenia in digestive tract cancers remains to be defined. We aimed to review the prognostic value of preoperative osteopenia in patients with digestive cancers.
METHODS
Cohort studies evaluating the prognostic value of preoperative osteopenia in digestive cancers (colorectal, esophageal, hepatic, bile duct, and pancreatic cancer) were searched using electronic databases and trial registries. The exposure was defined as low BMD estimated by computed tomography at 11 thoracic vertebra, while comparator was normal BMD. The primary outcomes were overall survival and recurrence-free survival for osteopenia. Random effect meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence.
RESULTS
A total of 11 studies (2230 patients) were included. Osteopenia was an independent risk factor for overall survival (hazard ratio [HR] = 2.02, 95% CI = 1.47 to 2.78; I = 74%), along with sarcopenia. Osteopenia also predicted poor recurrence-free survival (HR = 1.96, 95% CI = 1.36 to 2.81; I = 85%). In subgroup analyses, osteopenia predicted prognosis in colorectal, esophageal, hepatic, and bile duct cancers, but not in pancreatic cancer. The certainty of the evidence was low due to inconsistency and publication bias.
CONCLUSION
Osteopenia may be independently associated with poor prognosis in patients with digestive tract cancer. Further studies are needed to establish the relevance of osteopenia in the operative prognosis of these patients.
Topics: Bone Diseases, Metabolic; Humans; Pancreatic Neoplasms; Prognosis; Sarcopenia; Tomography, X-Ray Computed
PubMed: 35149903
DOI: 10.1007/s11657-022-01060-6 -
Cancers Apr 2021Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the... (Review)
Review
Ductal Dilatation of ≥5 mm in Intraductal Papillary Mucinous Neoplasm Should Trigger the Consideration for Pancreatectomy: A Meta-Analysis and Systematic Review of Resected Cases.
Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the diagnostic value of the main pancreatic duct (MPD) diameter for detecting IPMN malignancy using a meta-analysis of published data of resected IPMNs. Collected from a comprehensive literature search, the articles included in this analysis must report malignancy cases (high-grade dysplasia (HGD) and invasive carcinoma (IC)) and MPD diameter so that two MPD cut-offs could be created. The sensitivity, specificity, and odds ratios of the two cutoffs for predicting malignancy were calculated. A review of 1493 articles yielded 20 retrospective studies with 3982 resected cases. A cutoff of ≥5 mm is more sensitive than the ≥10 mm cutoff and has pooled sensitivity of 72.20% and 75.60% for classification of HGD and IC, respectively. Both MPD cutoffs of ≥5 mm and ≥10 mm were associated with malignancy (OR = 4.36 (95% CI: 2.82, 6.75) vs. OR = 3.18 (95% CI: 2.25, 4.49), respectively). The odds of HGD and IC for patients with MPD ≥5 mm were 5.66 (95% CI: 3.02, 10.62) and 7.40 (95% CI: 4.95, 11.06), respectively. OR of HGD and IC for MPD ≥10 mm cutoff were 4.36 (95% CI: 3.20, 5.93) and 4.75 (95% CI: 2.39, 9.45), respectively. IPMN with MPD of >5 mm could very likely be malignant. In selected IPMN patients, pancreatectomy should be considered when MPD is >5 mm.
PubMed: 33922344
DOI: 10.3390/cancers13092031 -
Journal of Clinical Gastroenterology Apr 2023Malignant biliary strictures (MBS) are very aggressive and cannot be diagnosed in the early stages due to their asymptomatic nature. Stenting the stricture area of the... (Meta-Analysis)
Meta-Analysis
BACKGROUND/AIMS
Malignant biliary strictures (MBS) are very aggressive and cannot be diagnosed in the early stages due to their asymptomatic nature. Stenting the stricture area of the biliary tree is palliative treatment but has poor survival time. Radiofrequency ablation plus stent (RFA+S) have been recently used to improve the survival and stent patency time in patients with MBS. In this systematic review and meta-analysis, we tried to evaluate the efficacy and safety of radiofrequency ablation.
MATERIALS AND METHODS
Study search up to December 2021 was performed in different medical databases such as PubMed, Web of Science, and Cochrane library, etc. We selected eligible studies reporting survival time, stent patency time, and adverse events in patients with MBS. We compare the outcomes of RFA+S and stent-alone treatment groups.
RESULTS
A total of 15 studies (6 randomized controlled trials and 9 observational studies) with 1815 patients were included for meta-analysis of which 701 patients were in RFA+S group and 1114 patients in the stent-alone group. Pooled mean difference of survival time was 2.88 months (95% CI: 1.78-3.97) and pooled mean difference of stent patency time was 2.11 months (95% CI: 0.91-3.30) and clinical success risk ratio was 1.05 (95% CI: 1.01-1.09). Risk ratios for adverse events are given; Bleeding 0.84 (95% CI: 0.34-2.11), abdominal pain 1.06 (95% CI: 0.79-1.40), pancreatitis 0.93 (95% CI: 0.43-2.01), cholangitis 1.07 (95% CI: 0.72-1.59), and stent dysfunction 0.87 (95% CI: 0.70-1.07).
CONCLUSIONS
Radiofrequency ablation is involved in increased survival and stent patency time for MBS patients. With the help of better techniques, adverse events can be limited.
Topics: Humans; Constriction, Pathologic; Catheter Ablation; Radiofrequency Ablation; Cholestasis; Stents; Treatment Outcome; Bile Duct Neoplasms; Randomized Controlled Trials as Topic
PubMed: 36628465
DOI: 10.1097/MCG.0000000000001810 -
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 -
Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.The Cochrane Database of Systematic... Jun 2023Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have...
BACKGROUND
Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have been used in some centres to reduce POPF rate. However, the use of fibrin sealant during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2020.
OBJECTIVES
To evaluate the benefits and harms of fibrin sealant use for the prevention of POPF (grade B or C) in people undergoing pancreatic surgery compared to no fibrin sealant use.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 09 March 2023, together with reference checking, citation searching, and contacting study authors to identify additional studies.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included 14 RCTs, randomising 1989 participants, comparing fibrin sealant use versus no fibrin sealant use for different locations: stump closure reinforcement (eight trials), pancreatic anastomosis reinforcement (five trials), or main pancreatic duct occlusion (two trials). Six RCTs were carried out in single centres; two in dual centres; and six in multiple centres. One RCT was conducted in Australia; one in Austria; two in France; three in Italy; one in Japan; two in the Netherlands; two in South Korea; and two in the USA. The mean age of the participants ranged from 50.0 years to 66.5 years. All RCTs were at high risk of bias. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included eight RCTs involving 1119 participants: 559 were randomised to the fibrin sealant group and 560 to the control group after distal pancreatectomy. Fibrin sealant use may result in little to no difference in the rate of POPF (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.73 to 1.21; 5 studies, 1002 participants; low-certainty evidence) and overall postoperative morbidity (RR 1.20, 95% CI 0.98 to 1.48; 4 studies, 893 participants; low-certainty evidence). After fibrin sealant use, approximately 199 people (155 to 256 people) out of 1000 developed POPF compared with 212 people out of 1000 when no fibrin sealant was used. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto odds ratio (OR) 0.39, 95% CI 0.12 to 1.29; 7 studies, 1051 participants; very low-certainty evidence) and total length of hospital stay (mean difference (MD) 0.99 days, 95% CI -1.83 to 3.82; 2 studies, 371 participants; very low-certainty evidence). Fibrin sealant use may reduce the reoperation rate slightly (RR 0.40, 95% CI 0.18 to 0.90; 3 studies, 623 participants; low-certainty evidence). Serious adverse events were reported in five studies (732 participants), and there were no serious adverse events related to fibrin sealant use (low-certainty evidence). The studies did not report quality of life or cost-effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included five RCTs involving 519 participants: 248 were randomised to the fibrin sealant group and 271 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF (RR 1.34, 95% CI 0.72 to 2.48; 3 studies, 323 participants; very low-certainty evidence), postoperative mortality (Peto OR 0.24, 95% CI 0.05 to 1.06; 5 studies, 517 participants; very low-certainty evidence), reoperation rate (RR 0.74, 95% CI 0.33 to 1.66; 3 studies, 323 participants; very low-certainty evidence), and total hospital cost (MD -1489.00 US dollars, 95% CI -3256.08 to 278.08; 1 study, 124 participants; very low-certainty evidence). After fibrin sealant use, approximately 130 people (70 to 240 people) out of 1000 developed POPF compared with 97 people out of 1000 when no fibrin sealant was used. Fibrin sealant use may result in little to no difference both in overall postoperative morbidity (RR 1.02, 95% CI 0.87 to 1.19; 4 studies, 447 participants; low-certainty evidence) and in total length of hospital stay (MD -0.33 days, 95% CI -2.30 to 1.63; 4 studies, 447 participants; low-certainty evidence). Serious adverse events were reported in two studies (194 participants), and there were no serious adverse events related to fibrin sealant use (very low-certainty evidence). The studies did not report quality of life. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two RCTs involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto OR 1.41, 95% CI 0.63 to 3.13; 2 studies, 351 participants; very low-certainty evidence), overall postoperative morbidity (RR 1.16, 95% CI 0.67 to 2.02; 2 studies, 351 participants; very low-certainty evidence), and reoperation rate (RR 0.85, 95% CI 0.52 to 1.41; 2 studies, 351 participants; very low-certainty evidence). Fibrin sealant use may result in little to no difference in the total length of hospital stay (median 16 to 17 days versus 17 days; 2 studies, 351 participants; low-certainty evidence). Serious adverse events were reported in one study (169 participants; low-certainty evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report POPF, quality of life, or cost-effectiveness.
AUTHORS' CONCLUSIONS
Based on the current available evidence, fibrin sealant use may result in little to no difference in the rate of POPF in people undergoing distal pancreatectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF in people undergoing pancreaticoduodenectomy. The effect of fibrin sealant use on postoperative mortality is uncertain in people undergoing either distal pancreatectomy or pancreaticoduodenectomy.
Topics: Humans; Middle Aged; Fibrin Tissue Adhesive; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 37335216
DOI: 10.1002/14651858.CD009621.pub5