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Digestive Diseases and Sciences May 2022Over 17.7 million gastrointestinal (GI) endoscopic procedures are performed annually, contributing to 68% of all endoscopic procedures in the United States. Usually,... (Review)
Review
Over 17.7 million gastrointestinal (GI) endoscopic procedures are performed annually, contributing to 68% of all endoscopic procedures in the United States. Usually, endoscopic procedures are low risk, but adverse events may occur, including cardiopulmonary complications, bleeding, perforation, pancreatitis, cholangitis, and infection. Infections after the GI endoscopies most commonly result from the patient's endogenous gut flora. Although many studies have reported infection after GI endoscopic procedures, a true estimate of the incidence rate of post-endoscopy infection is lacking. In addition, the infection profile and causative organisms have evolved over time. In recent times, multi-drug-resistant microorganisms have emerged as a cause of outbreaks of endoscope-associated infections (EAI). In addition, lapses in endoscope reprocessing have been reported, with some but not all outbreaks in recent times. This systematic review summarizes the demographical, clinical, and management data of EAI events reported in the literature. A total of 117 articles were included in the systematic review, with the majority reported from North America and Western Europe. The composite infection rate was calculated to be 0.2% following GI endoscopic procedures, 0.8% following ERCP, 0.123% following non-ERCP upper GI endoscopic procedures, and 0.073% following lower GI endoscopic procedures. Pseudomonas aeruginosa was the most common culprit organism, followed by other Enterobacteriaceae groups of organisms and Gram-positive cocci. We have also elaborated different prevention methods such as antimicrobial prophylaxis, adequate sterilization methods for reprocessing endoscopes, periodic surveillance, and current evidence supporting their utilization. Finally, we discuss disposable endoscopes, which could be an alternative to reprocessing to minimize the chances of EAIs with their effects on the environmental and financial situation.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Communicable Diseases; Disease Outbreaks; Endoscopes; Endoscopy, Gastrointestinal; Enterobacteriaceae; Europe; Humans
PubMed: 35262904
DOI: 10.1007/s10620-022-07441-8 -
The Journal of Trauma and Acute Care... Nov 2022Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS).
METHODS
PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones.
RESULTS
A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones.
CONCLUSION
This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches.
LEVEL OF EVIDENCE
Systematic Review/Meta Analysis; Level III.
Topics: Humans; Gallstones; Sphincterotomy, Endoscopic; Cholecystectomy, Laparoscopic; Network Meta-Analysis; Choledocholithiasis; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct
PubMed: 35939370
DOI: 10.1097/TA.0000000000003755 -
JAMA Surgery Jun 2023The incidence of chronic pancreatitis is 5 to 12 per 100 000 adults in industrialized countries, and the incidence is increasing. Treatment is multimodal, and involves...
IMPORTANCE
The incidence of chronic pancreatitis is 5 to 12 per 100 000 adults in industrialized countries, and the incidence is increasing. Treatment is multimodal, and involves nutrition optimization, pain management, and when indicated, endoscopic and surgical intervention.
OBJECTIVES
To summarize the most current published evidence on etiology, diagnosis, and management of chronic pancreatitis and its associated complications.
EVIDENCE REVIEW
A literature search of Web of Science, Embase, Cochrane Library, and PubMed was conducted for publications between January 1, 1997, and July 30, 2022. Excluded from review were the following: case reports, editorials, study protocols, nonsystematic reviews, nonsurgical technical publications, studies pertaining to pharmacokinetics, drug efficacy, pilot studies, historical papers, correspondence, errata, animal and in vitro studies, and publications focused on pancreatic diseases other than chronic pancreatitis. Ultimately, the highest-level evidence publications were chosen for inclusion after analysis by 2 independent reviewers.
FINDINGS
A total of 75 publications were chosen for review. First-line imaging modalities for diagnosis of chronic pancreatitis included computed tomography and magnetic resonance imaging. More invasive techniques such as endoscopic ultrasonography allowed for tissue analysis, and endoscopic retrograde cholangiopancreatography provided access for dilation, sphincterotomy, and stenting. Nonsurgical options for pain control included behavior modification (smoking cessation, alcohol abstinence), celiac plexus block, splanchnicectomy, nonopioid pain medication, and opioids. Supplemental enzymes should be given to patients with exocrine insufficiency to avoid malnutrition. Surgery was superior to endoscopic interventions for long-term pain control, and early surgery (<3 years from symptom onset) had more superior outcomes than late surgery. Duodenal preserving strategies were preferred unless there was suspicion of cancer.
CONCLUSIONS AND RELEVANCE
Results of this systematic review suggest that patients with chronic pancreatitis had high rates of disability. Strategies to improve pain control through behavioral modification, endoscopic measures, and surgery must also accompany management of the sequalae of complications that arise from endocrine and exocrine insufficiency.
Topics: Humans; Pancreatitis, Chronic; Cholangiopancreatography, Endoscopic Retrograde; Pain; Pain Management; Endosonography
PubMed: 37074693
DOI: 10.1001/jamasurg.2023.0367 -
World Journal of Gastroenterology Aug 2019Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis...
BACKGROUND
Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.AIMSTo study the published evidence and systematically review the literature on the prevention and treatment for PEP.
METHODS
A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms "Post endoscopic retrograde cholangiopancreatography pancreatitis" AND "prevention" through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.
RESULTS
726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.
CONCLUSION
Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.
Topics: Administration, Rectal; Anti-Inflammatory Agents; Biliary Tract Diseases; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Drainage; Humans; Pancreas; Pancreatitis; Phosphodiesterase 5 Inhibitors; Postoperative Complications; Preoperative Care; Risk Assessment; Risk Factors; Somatostatin; Sphincter of Oddi; Stents
PubMed: 31413535
DOI: 10.3748/wjg.v25.i29.4019 -
JAMA Surgery Jul 2018Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared. (Comparative Study)
Comparative Study Meta-Analysis
Comparison of Efficacy and Safety of 4 Combinations of Laparoscopic and Intraoperative Techniques for Management of Gallstone Disease With Biliary Duct Calculi: A Systematic Review and Network Meta-analysis.
IMPORTANCE
Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared.
OBJECTIVES
To compare the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi.
DATA SOURCES
MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used were LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations.
STUDY SELECTION
Randomized clinical trials comparing at least 2 of the following strategies: preoperative endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy (LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative ERCP (PostERCP).
DATA EXTRACTION AND SYNTHESIS
A frequentist random-effects network meta-analysis was performed. The surface under the cumulative ranking curve (SUCRA) was used to show the probability that each approach would be the best for each outcome.
MAIN OUTCOMES AND MEASURES
Primary outcomes were the safety to efficacy ratio using overall mortality and morbidity rates as the main indicators of safety and the success rate as an indicator of efficacy. Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate.
RESULTS
The 20 trials comprised 2489 patients (and 2489 procedures). Laparoscopic cholecystectomy plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P = .04). Heterogeneity was observed for success rate (τ, 0.8), operative time (τ, >1), length of stay (τ, >1), and total cost (τ, >1).
CONCLUSIONS AND RELEVANCE
The combined LC and IntraERCP approach had the greatest odds to be the safest and appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy, Laparoscopic; Choledocholithiasis; Cholelithiasis; Combined Modality Therapy; Gallstones; Humans; Network Meta-Analysis; Treatment Outcome
PubMed: 29847616
DOI: 10.1001/jamasurg.2018.1167 -
The Journal of Pediatrics Jul 2012To perform a systematic review evaluating the value of abdominal radiography, colonic transit time (CTT), and rectal ultrasound scanning in the diagnosis of idiopathic... (Review)
Review
OBJECTIVE
To perform a systematic review evaluating the value of abdominal radiography, colonic transit time (CTT), and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children.
STUDY DESIGN
Eligible studies were those assessing diagnostic accuracy of abdominal radiography, CTT, or rectal ultrasound scanning in children suspected for idiopathic constipation. Methodological quality of the included studies was assessed with the Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews checklist.
RESULTS
One systematic review summarized 6 studies on abdominal radiography until 2004. The additional 9 studies evaluated abdominal radiography (n = 2), CTT (n = 3), and ultrasound scanning (n = 4). All studies except two used a case-control study design, which will lead to overestimation of test accuracy. Furthermore, none of the studies interpreted the results of the abdominal radiography, ultrasound scanning, or CTT without knowledge of the clinical diagnosis of constipation. The sensitivity of abdominal radiography, as studied in 6 studies, ranged from 80% (95% CI, 65-90) to 60% (95% CI, 46-72), and its specificity ranged from 99% (95% CI, 95-100) to 43% (95% CI, 18-71). Only one study presented test characteristics of CTT, and two studies presented test characteristics of ultrasonography.
CONCLUSION
We found insufficient evidence for a diagnostic association between clinical symptoms of constipation and fecal loading on abdominal radiographs, CTT, and rectal diameter on ultrasound scanning in children.
Topics: Child; Colon; Constipation; Gastrointestinal Transit; Humans; Radiography, Abdominal; Rectum; Ultrasonography
PubMed: 22341242
DOI: 10.1016/j.jpeds.2011.12.045 -
European Radiology Jun 2016Abdominal radiography is frequently used in acute abdominal non-traumatic pain despite the availability of more advanced diagnostic modalities. This study evaluates the... (Comparative Study)
Comparative Study Review
OBJECTIVES
Abdominal radiography is frequently used in acute abdominal non-traumatic pain despite the availability of more advanced diagnostic modalities. This study evaluates the diagnostic accuracy of low-dose CT compared with abdominal radiography, at similar radiation dose levels.
METHODS
Fifty-eight patients were imaged with both methods and were reviewed independently by three radiologists. The reference standard was obtained from the diagnosis in medical records. Sensitivity and specificity were calculated. A systematic review was performed after a literature search, finding a total of six relevant studies including the present.
RESULTS
Overall sensitivity with 95 % CI for CT was 75 % (66-83 %) and 46 % (37-56 %) for radiography. Specificity was 87 % (77-94 %) for both methods. In the systematic review the overall sensitivity for CT varied between 75 and 96 % with specificity from 83 to 95 % while the overall sensitivity for abdominal radiography varied between 30 and 77 % with specificity 75 to 88 %.
CONCLUSIONS
Based on the current study and available evidence, low-dose CT has higher diagnostic accuracy than abdominal radiography and it should, where logistically possible, replace abdominal radiography in the workup of adult patients with acute non-traumatic abdominal pain.
KEY POINTS
• Low-dose CT has a higher diagnostic accuracy than radiography. • A systematic review shows that CT has better diagnostic accuracy than radiography. • Radiography has no place in the workup of acute non-traumatic abdominal pain.
Topics: Abdominal Pain; Adult; Aged; Aged, 80 and over; Diagnostic Errors; Diverticulitis, Colonic; Female; Hernia, Abdominal; Hernia, Inguinal; Humans; Intestinal Obstruction; Male; Middle Aged; Observer Variation; Prospective Studies; Radiation Dosage; Radiography, Abdominal; Sensitivity and Specificity; Sigmoid Neoplasms; Tomography, X-Ray Computed; Young Adult
PubMed: 26385800
DOI: 10.1007/s00330-015-3984-9 -
International Journal of Evidence-based... Jun 2020Previous studies, some dating back several decades, have recommended that the use of plain abdominal radiography should be curbed, particularly with the growth of more... (Meta-Analysis)
Meta-Analysis
AIM
Previous studies, some dating back several decades, have recommended that the use of plain abdominal radiography should be curbed, particularly with the growth of more accurate imaging modalities. However, evidence from referral data suggests that plain abdominal radiography continues to be a commonly requested examination. The aim of this review was to explore the gap between evidence and practice by re-examining the evidence using a robust methodology, investigating the diagnostic accuracy of plain abdominal radiography.
METHODS
Studies were identified from electronic databases and reference lists. Eligible studies provided data as to the sensitivity and specificity of plain abdominal radiography for either acute abdominal pain (Group A) or suspected intestinal obstruction (Group B). Version 2 of the Quality Assessment of Diagnostic Accuracy Studies was used to assess the quality of studies and hierarchical summary receiver operator characteristic curves and coupled forest plots were generated.
RESULTS
Four studies evaluated plain abdominal radiography for acute abdominal pain (Group A) and 10 for suspected intestinal obstruction (Group B). Two studies investigated both presentations and were included in both groups. Methodological quality of studies was moderately high, though incorporation bias was a common limitation. Sensitivity for Group A studies ranged from 30 to 46%, with specificity from 75 to 88%. For Group B, the range of sensitivity was 48 to 96% and specificity from 50 to 100%.
CONCLUSION
The results suggest that use of plain abdominal radiography could be substantially reduced, particularly for patients with undifferentiated acute abdominal pain. While some guidelines exist, there is sound argument for clinical decision rules for abdominal imaging to inform evidence-based clinical decision-making and radiology referrals.
Topics: Abdominal Pain; Humans; Intestinal Obstruction; Professional Practice Gaps; ROC Curve; Radiography; Sensitivity and Specificity
PubMed: 32141947
DOI: 10.1097/XEB.0000000000000218 -
Archives of Pediatrics & Adolescent... Jul 2005Constipation is a common problem in children. Diagnosis is based on clinical features. In case of doubt about the presence of constipation, the existence of fecal... (Review)
Review
BACKGROUND
Constipation is a common problem in children. Diagnosis is based on clinical features. In case of doubt about the presence of constipation, the existence of fecal retention can be evaluated on plain abdominal radiography.
OBJECTIVES
To describe and to assess the evidence from observational, controlled studies concerning the association between abdominal radiography and symptoms and signs related to constipation in children.
METHODS
MEDLINE was searched from inception to April 2004 using a specified search strategy. Studies that fulfilled predefined criteria were assessed for methodological quality. Study characteristics and associations were extracted and the results were summarized according to a best-evidence synthesis.
RESULTS
Of the 392 publications identified, 6 studies met the inclusion criteria. Only 2 studies were of high methodological quality. The best-evidence synthesis yielded conflicting evidence for an association between a clinical and a radiological diagnosis of constipation. The likelihood ratio (LR) in 2 high-quality studies was close to 1 (LR, 1.2; 95% confidence interval [CI], 1.0-1.4; and LR, 1.0; 95% CI, 0.5-1.6). Conflicting evidence was found for an association between digital rectal examination and fecal impaction on radiography. Limited evidence was found for an association between a history of hard stool and a finding of rebound tenderness and radiography (LR, 1.2; 95% CI, 1.0-1.4; and LR, 1.1; 95% CI, 1.0-1.2, respectively).
CONCLUSIONS
The limited amount of data available shows conflicting evidence for an association between clinical symptoms of constipation and fecal loading on abdominal radiographs in children. The recommendation to perform a plain abdominal radiograph in case of doubt of the presence of constipation in a child cannot be supported. Further research of good methodological quality is needed.
Topics: Child; Child, Preschool; Constipation; Humans; Radiography, Abdominal
PubMed: 15997002
DOI: 10.1001/archpedi.159.7.671 -
Radiography (London, England : 1995) May 2021Radiation dose variation within and among Computed Tomography (CT) centres is commonly reported. This work systematically reviewed published articles on adult Diagnostic... (Review)
Review
OBJECTIVES
Radiation dose variation within and among Computed Tomography (CT) centres is commonly reported. This work systematically reviewed published articles on adult Diagnostic Reference Levels (DRLs) for the brain, chest and abdomen to determine the causes and extent of variation. A systematic literature search and review was performed in selected databases containing leading journals in radiography, radiology and medical physics using carefully defined search terms related to CT and DRLs. The quality of the included articles was determined using the Effective Public Health Practise Project tool for quantitative studies.
KEY FINDINGS
The 54 articles reviewed include: 45 studies using human data, 8 studies using phantom data, and one study with both human and phantom data. The main comparator in between studies was the dose indices used in reporting DRLs. DRL variations of up to a factor of 2 for the same procedure were noted in phantom studies, and up to a factor of 3 in human studies. Sources of variation include the type of scanner, the age of the scanner, differences in protocols, variations in patients, as well as variations in study design. Different combinations of dose indices were reported: volume computed tomography dose index (CTDIvol) and dose length product (DLP) (59%); DLP only (11%); weighted computed tomography dose index (CTDIw) and DLP (9%); CTDIvol only (7%); CTDIvol, DLP and effective dose (ED) (6%); CTDIw only (4%); CTDIvol, DLP and size specific dose estimate (SSDE) (1%) and CTDIw, CTDIvol and DLP (1%). The use of different dose indices limited dose comparison between studies.
CONCLUSION
The study noted a 2-3 fold variation in DRLs between studies for the same procedure. The causes of variation are reported and include study design, scanner technology and the use of different dose indices.
IMPLICATIONS FOR PRACTICE
There is a need for standardisation of CT DRLs in line with the International Commission on Radiological Protection recommendations to reduce dose variation and facilitate dose comparison.
Topics: Abdomen; Adult; Brain; Diagnostic Reference Levels; Humans; Radiation Dosage; Reference Values; Tomography, X-Ray Computed
PubMed: 32948454
DOI: 10.1016/j.radi.2020.08.011