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BMJ Open May 2023Hepatectomy is the best treatment for patients with intrahepatic cholangiocarcinoma (ICC) at present, but there has been controversy about the width of surgical margins.... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Hepatectomy is the best treatment for patients with intrahepatic cholangiocarcinoma (ICC) at present, but there has been controversy about the width of surgical margins. In this study, we systematically investigated the effects of different surgical margin widths on the prognosis of patients with ICC undergoing hepatectomy.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
PubMed, Embase and Web of Science databases were systematically searched from inception to June 2022.
ELIGIBILITY CRITERIA
Cohort studies reported in English with patients who underwent negative marginal (R0) resection were included. The effects of surgical margin width on overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS) in patients with ICC were assessed.
DATA EXTRACTION AND SYNTHESIS
Two investigators independently conducted literature screening and data extraction. Risk of bias was assessed using funnel plots and quality was assessed by the Newcastle-Ottawa Scale. Forest plots of HRs and their 95% CIs for outcome indicators were plotted. Heterogeneity was assessed and determined quantitatively using I, and the stability of the study results was evaluated using sensitivity analysis. Analyses were performed using Stata software.
RESULTS
Nine studies were included. With the wide margin group (≥10 mm) as the control, pooled HR of OS in the narrow margin group (<10 mm) was 1.54 (95% CI 1.34 to 1.77). HRs of OS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.88 (1.45 to 2.42), 1.33 (1.03 to 1.72) and 1.49 (1.20 to 1.84), respectively. Pooled HR of DFS in the narrow margin group (<10 mm) was 1.51 (1.14 to 2.00). Pooled HR of RFS in the narrow margin group (<10 mm) was 1.35 (1.19 to 1.54). HRs of RFS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.38 (1.07 to 1.78), 1.39 (1.11 to 1.74) and 1.30 (1.06 to 1.60), respectively. Neither lymph node lesions (HR 1.44, 95% CI 1.22 to 1.70) nor lymph node invasion (2.14, 1.39 to 3.28) was favourable for postoperative OS in patients with ICC. Lymph node metastasis (1.31, 1.09 to 1.57) was unfavourable for RFS in patients with ICC.
CONCLUSION
Patients with ICC who underwent curative hepatectomy with a negative margin ≥10 mm may have a long-term survival advantage, but lymph node dissection also needs to be considered. In addition, tumour-related pathological features need to be explored to see if they affect the surgical outcome of R0 margins.
Topics: Humans; Margins of Excision; Survival Rate; Bile Duct Neoplasms; Cholangiocarcinoma; Prognosis; Hepatectomy; Bile Ducts, Intrahepatic
PubMed: 37156579
DOI: 10.1136/bmjopen-2022-067222 -
World Journal of Surgery Jun 2021The superiority of Blumgart anastomosis (BA) over non-BA duct to mucosa (non-BA DtoM) still remains under debate. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The superiority of Blumgart anastomosis (BA) over non-BA duct to mucosa (non-BA DtoM) still remains under debate.
METHODS
We performed a systematic search of studies comparing BA to non-BA DtoM. The primary endpoint was CR-POPF. Postoperative morbidity and mortality, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), reoperation rate, and length of stay (LOS) were evaluated as secondary endpoints. The meta-analysis was carried out using random effect. The results were reported as odds ratio (OR), risk difference (RD), weighted mean difference (WMD), and number needed to treat (NNT).
RESULTS
Twelve papers involving 2368 patients: 1075 BA and 1193 non-BA DtoM were included. Regarding the primary endpoint, BA was superior to non-BA DtoM (RD = 0.10; 95% CI: -0.16 to -0.04; NNT = 9). The multivariate ORs' meta-analysis confirmed BA's protective role (OR 0.26; 95% CI: 0.09 to 0.79). BA was superior to DtoM regarding overall morbidity (RD = -0.10; 95% CI: -0.18 to -0.02; NNT = 25), PPH (RD = -0.03; 95% CI -0.06 to -0.01; NNT = 33), and LOS (- 4.2 days; -7.1 to -1.2 95% CI).
CONCLUSION
BA seems to be superior to non-BA DtoM in avoiding CR-POPF.
Topics: Anastomosis, Surgical; Humans; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Reoperation
PubMed: 33721074
DOI: 10.1007/s00268-021-06039-x -
World Journal of Gastrointestinal... Aug 2021Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones, strictures,...
BACKGROUND
Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones, strictures, and pancreatic fluid collections. Most studies detailing endotherapy, however, have focused on technical success outcomes such as stone clearance or stricture resolution.
AIM
To review the effect of pancreatic endotherapy on patient-centered outcomes.
METHODS
Systematic review of studies examining pancreatic endotherapy.
RESULTS
A total of 13 studies including 3 randomized clinical trials were included. The majority of studies found an improvement in quality of life with pancreatic endotherapy.
CONCLUSION
While pancreatic endotherapy does appear to improve quality of life, there are clear gaps in knowledge regarding many pancreatic endotherapy modalities. Furthermore, qualitative analysis is lacking in these studies and further work is needed to elucidate the patient experience with pancreatic endotherapy.
PubMed: 34512881
DOI: 10.4253/wjge.v13.i8.336 -
Endoscopy International Open Feb 2024Recent advances in endoscopic transmural treatment have improved the clinical outcomes of patients with pancreatic fluid collections (PFCs). However, there is still a... (Review)
Review
Recent advances in endoscopic transmural treatment have improved the clinical outcomes of patients with pancreatic fluid collections (PFCs). However, there is still a debate about the preventive effect of long-term placement of a transmural plastic stent (PS) on recurrence after successful endoscopic ultrasound (EUS)-guided treatment of PFCs. We conducted a systematic review and meta-analysis to evaluate PFC recurrence rates with and without a transmural PS after EUS-guided treatment. A systematic literature search of PubMed, Embase, and the Cochrane database was conducted to identify clinical studies comparing outcomes with and without transmural PS published until September 2022. Data on PFC recurrence and adverse events (AEs) were pooled using a random-effects model. Nine studies including 380 patients with long-term transmural PS and 289 patients without PS were identified. The rate of PFC recurrence was significantly lower in patients with transmural PS (pooled odds ratio [OR] = 0.23, 95% confidence interval [CI] [0.08-0.65], = 0.005). In a subgroup analysis limited to studies focusing on patients with disconnected pancreatic duct syndrome, which has been reported to be a risk factor for PFC recurrence, the OR was numerically lower than that for the entire cohort (OR = 0.14, 95% CI [0.04-0.46]). The rate of AEs was significantly higher with long-term transmural PS (OR = 14.77, 95% CI [4.21-51.83]). In this meta-analysis, long-term PS placement reduced the risk of PFC recurrence. Given the potential AEs of indwelling PS, further research is required to evaluate the overall benefits of long-term PS placement.
PubMed: 38348330
DOI: 10.1055/a-2226-1237 -
Health Technology Assessment... May 2023Early evidence suggests that using radiofrequency ablation as an adjunct to standard care (i.e. endoscopic retrograde cholangiopancreatography with stenting) may improve... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early evidence suggests that using radiofrequency ablation as an adjunct to standard care (i.e. endoscopic retrograde cholangiopancreatography with stenting) may improve outcomes in patients with malignant biliary obstruction.
OBJECTIVES
To assess the clinical effectiveness, cost-effectiveness and potential risks of endoscopic bipolar radiofrequency ablation for malignant biliary obstruction, and the value of future research.
DATA SOURCES
Seven bibliographic databases, three websites and seven trials registers were searched from 2008 until 21 January 2021.
REVIEW METHODS
The study inclusion criteria were as follows: patients with biliary obstruction caused by any form of unresectable malignancy; the intervention was reported as an endoscopic biliary radiofrequency ablation to ablate malignant tissue that obstructs the bile or pancreatic ducts, either to fit a stent (primary radiofrequency ablation) or to clear an obstructed stent (secondary radiofrequency ablation); the primary outcomes were survival, quality of life or procedure-related adverse events; and the study design was a controlled study, an observational study or a case report. Risk of bias was assessed using Cochrane tools. The primary analysis was meta-analysis of the hazard ratio of mortality. Subgroup analyses were planned according to the type of probe, the type of stent (i.e. metal or plastic) and cancer type. A de novo Markov model was developed to model cost and quality-of-life outcomes associated with radiofrequency ablation in patients with primary advanced bile duct cancer. Insufficient data were available for pancreatic cancer and secondary bile duct cancer. An NHS and Personal Social Services perspective was adopted for the analysis. A probabilistic analysis was conducted to estimate the incremental cost-effectiveness ratio for radiofrequency ablation and the probability that radiofrequency ablation was cost-effective at different thresholds. The population expected value of perfect information was estimated in total and for the effectiveness parameters.
RESULTS
Sixty-eight studies (1742 patients) were included in the systematic review. Four studies (336 participants) were combined in a meta-analysis, which showed that the pooled hazard ratio for mortality following primary radiofrequency ablation compared with a stent-only control was 0.34 (95% confidence interval 0.21 to 0.55). Little evidence relating to the impact on quality of life was found. There was no evidence to suggest an increased risk of cholangitis or pancreatitis, but radiofrequency ablation may be associated with an increase in cholecystitis. The results of the cost-effectiveness analysis were that the costs of radiofrequency ablation was £2659 and radiofrequency ablation produced 0.18 quality-adjusted life-years, which was more than no radiofrequency ablation on average. With an incremental cost-effectiveness ratio of £14,392 per quality-adjusted life-year, radiofrequency ablation was likely to be cost-effective at a threshold of £20,000 per quality-adjusted life-year across most scenario analyses, with moderate uncertainty. The source of the vast majority of decision uncertainty lay in the effect of radiofrequency ablation on stent patency.
LIMITATIONS
Only 6 of 18 comparative studies contributed to the survival meta-analysis, and few data were found concerning secondary radiofrequency ablation. The economic model and cost-effectiveness meta-analysis required simplification because of data limitations. Inconsistencies in standard reporting and study design were noted.
CONCLUSIONS
Primary radiofrequency ablation increases survival and is likely to be cost-effective. The evidence for the impact of secondary radiofrequency ablation on survival and of quality of life is limited. There was a lack of robust clinical effectiveness data and, therefore, more information is needed for this indication.
FUTURE WORK
Future work investigating radiofrequency ablation must collect quality-of-life data. High-quality randomised controlled trials in secondary radiofrequency ablation are needed, with appropriate outcomes recorded.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42020170233.
FUNDING
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 27, No. 7. See the NIHR Journals Library website for further project information.
Topics: Humans; Bile Duct Neoplasms; Cholestasis; Cost-Benefit Analysis; Cost-Effectiveness Analysis; Observational Studies as Topic; Quality of Life
PubMed: 37212444
DOI: 10.3310/YYMN9802 -
Asian Journal of Surgery Dec 2020Ampullary cancer is a relatively rare gastrointestinal malignancy. The purpose of this study was to evaluate prognostic factors for survival and assess the benefits of... (Meta-Analysis)
Meta-Analysis
Ampullary cancer is a relatively rare gastrointestinal malignancy. The purpose of this study was to evaluate prognostic factors for survival and assess the benefits of adjuvant therapy following pancreaticoduodenectomy for this entity. Medline and EMBASE databases were searched to identify eligible studies from January 2000 to August 2019. Review Manager 5.3 statistical software was used for meta-analysis. 71 studies met the inclusion criteria and were included in the analysis for a total of 8280 patients. The median (range) 5-year overall survival and disease-free survival rates were 58% (32-82%) and 51% (28-73%) respectively. In meta-analysis, age >65 years at diagnosis, tumor size >20 mm, poor differentiation, pancreaticobiliary histotype, pT3-4 stage disease, presence of metastatic lymph node, number of metastatic nodes, perineural invasion, lymphovascular invasion, vascular invasion, pancreatic invasion, and positive surgical margins were independently associated with worse overall survival, whereas adjuvant therapy was associated with improved overall survival. In summary, in patients with ampullary cancer undergoing pancreaticoduodenectomy, tumor factors are the main predictors of worse survival and adjuvant treatment confers a survival benefit.
Topics: Aged; Aged, 80 and over; Ampulla of Vater; Chemotherapy, Adjuvant; Common Bile Duct Neoplasms; Duodenal Neoplasms; Female; Humans; Male; Neoplasm Invasiveness; Neoplasm Metastasis; Pancreatic Neoplasms; Pancreaticoduodenectomy; Prognosis; Survival Rate
PubMed: 32249101
DOI: 10.1016/j.asjsur.2020.03.007 -
United European Gastroenterology Journal Oct 2020Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal...
Prophylactic total pancreatectomy in individuals at high risk of pancreatic ductal adenocarcinoma (PROPAN): systematic review and shared decision-making programme using decision tables.
BACKGROUND
Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm, may wish to discuss prophylactic total pancreatectomy but strategies to do so are lacking.
OBJECTIVE
To develop a shared decision-making programme for prophylactic total pancreatectomy using decision tables.
METHODS
Focus group meetings with patients were used to identify relevant questions. Systematic reviews were performed to answer these questions.
RESULTS
The first tables included hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm. No studies focused on prophylactic total pancreatectomy in these groups. In 52 studies (3570 patients), major morbidity after total pancreatectomy was 25% and 30-day mortality was 6%. After minimally invasive total pancreatectomy (seven studies, 35 patients) this was, respectively, 13% and 0%. Exocrine insufficiency-related symptoms occurred in 33%. Quality of life after total pancreatectomy was slightly lower compared with the general population.
CONCLUSION
The decision tables can be helpful for discussing prophylactic total pancreatectomy with individuals at high risk of pancreatic ductal adenocarcinoma.
Topics: Carcinoma, Pancreatic Ductal; Decision Making, Shared; Decision Support Techniques; Disease Progression; Exocrine Pancreatic Insufficiency; Humans; Pancreatectomy; Pancreatic Ducts; Pancreatic Neoplasms; Pancreatitis, Chronic; Postoperative Complications; Prophylactic Surgical Procedures; Quality of Life; Risk Assessment; Treatment Outcome
PubMed: 32703081
DOI: 10.1177/2050640620945534 -
The Cochrane Database of Systematic... Mar 2022Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However,... (Review)
Review
BACKGROUND
Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP.
OBJECTIVES
To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases.
SEARCH METHODS
For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update.
SELECTION CRITERIA
Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP.
DATA COLLECTION AND ANALYSIS
Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis.
MAIN RESULTS
15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses.
AUTHORS' CONCLUSIONS
There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.
Topics: Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct; Humans; Pancreatitis; Sphincterotomy, Endoscopic
PubMed: 35349163
DOI: 10.1002/14651858.CD009662.pub3 -
Scientific Reports Oct 2020Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have... (Comparative Study)
Comparative Study Meta-Analysis
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
Topics: Adult; Aged; Aged, 80 and over; Anastomosis, Surgical; Female; Humans; Incidence; Male; Middle Aged; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Treatment Outcome; Young Adult
PubMed: 33087777
DOI: 10.1038/s41598-020-74812-4 -
World Journal of Surgical Oncology Apr 2020To compare the efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in preoperative biliary drainage (PBD). (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
To compare the efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in preoperative biliary drainage (PBD).
METHODS
ENBD and EBS related literature of patients with malignant biliary obstruction published before September 2019 were collected from PubMed, EMBASE, and Cochrane Library for comparison analysis. Revman 5.3 statistical software was used for analysis.
RESULTS
Nine studies were used for our comparative study. A total of 1435 patients were included, which consisted of 813 in the ENBD group and 622 in the EBS group. Meta-analysis showed that patients with malignant biliary obstruction who received ENBD had reductions in the rates of preoperative cholangitis (RR = 0.46, 95% CI = 0.34-0.62, P < 0.00001), preoperative pancreatitis (RR = 0.69, 95% CI = 0.50-0.95, P = 0.02), stent dysfunction (RR = 0.58, 95% CI = 0.43-0.80, P = 0.0008), morbidity (RR = 0.77, 95% CI = 0.64-0.93, P = 0.007), and postoperative pancreatic fistula (RR = 0.65, 95% CI = 0.45-0.92, P = 0.02) compared with patients who received EBS.
CONCLUSIONS
The rates of preoperative cholangitis, preoperative pancreatitis, post-operative pancreatic fistula, stent dysfunction, and morbidity of ENBD patients were lower than those of EBS patients. In clinical practice, the physical condition of each patient and their tolerance should be fully considered. ENBD should be given priority. EBS should be replaced if stent dysfunction or intolerance occurs.
Topics: Bile Duct Neoplasms; Cholangitis; Cholestasis; Drainage; Endoscopy; Humans; Pancreaticoduodenectomy; Pancreatitis; Preoperative Care; Stents
PubMed: 32276634
DOI: 10.1186/s12957-020-01848-1