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PloS One 2014Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP).... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the target patients, the type of NSAID, the route of administration and the time of drug delivery remain unclear, as well as the potential efficacy in reducing the severity of pancreatitis, length of hospital stay and mortality. The objective of the study was to evaluate these questions by performing a systematic review and meta-analysis.
METHODS
Multiple searches were performed in the main databases. Randomized controlled trials (RCTs) comparing NSAIDs vs. placebo in the prevention of post-ERCP pancreatitis were included. Primary endpoint of the study was the efficacy for pancreatitis prevention. Sub-analyses were performed to determine the risk reduction in high and low risk patients, and to define optimal time, route of administration, and type of NSAID. Secondary endpoints were safety, moderate to severe pancreatitis prevention and reduction of hospital stay and mortality.
RESULTS
Nine RCTs enrolling 2133 patients were included. The risk of pancreatitis was lower in the NSAID group than in the placebo group (RR 0.51; 95%CI 0.39-0.66). The number needed to treat was 14. The risk of moderate to severe pancreatitis was also lower in the NSAID group. (RR 0.46; 95%CI 0.28-0.76). No adverse events related to NSAID use were reported. NSAIDs were effective in both high-risk and unselected patients (RR 0.53; 95%CI 0.30-0.93 and RR 0.57; 95%CI 0.37-0.88). In the subanalyses, only rectal administration of either indomethacin (RR 0.54; 95%CI 0.38-0.75) or diclofenac (RR 0.42; 95%CI 0.21-0.84) was shown to be effective. There were not enough data to perform a meta-analysis in hospital stay reduction. No deaths occurred.
CONCLUSION
A single rectal dose of indomethacin or diclofenac before or immediately after ERCP is safe and prevents procedure-related pancreatitis both in high risk and in unselected patients.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Cholangiopancreatography, Endoscopic Retrograde; Hospital Mortality; Humans; Incidence; Length of Stay; Pancreatitis; Randomized Controlled Trials as Topic; Risk; Severity of Illness Index; Time Factors
PubMed: 24675922
DOI: 10.1371/journal.pone.0092922 -
ANZ Journal of Surgery Apr 2021Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken... (Review)
Review
BACKGROUND
Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy.
METHODS
Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed.
RESULTS
A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches.
CONCLUSION
Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.
Topics: Aged; Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Common Bile Duct; Dilatation; Humans; Risk Factors; Sphincterotomy, Endoscopic; Treatment Outcome
PubMed: 32815266
DOI: 10.1111/ans.16211 -
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 -
Journal of Gastrointestinal Surgery :... Nov 2022Routine rectal administration of 100 mg of diclofenac or indomethacin was demonstrated to be an effective prevention method to prevent post-endoscopic retrograde... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Routine rectal administration of 100 mg of diclofenac or indomethacin was demonstrated to be an effective prevention method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The systematic review and meta-analysis aimed to estimate the incidence and severity of post-ERCP pancreatitis (PEP) and explore the discrepancies of PEP incidences among different subgroups.
METHODS
The PubMed, Web of Science, and Ovid EMBASE databases were searched for studies published until December 2020. Only randomized controlled trials (RCTs) reported rectal administration of 100 mg or higher doses of diclofenac or indomethacin, with PEP as the primary outcomes were eligible for inclusion. The overall and severity of PEP were estimated. Subgroup analysis was performed based on geographic regions, risk level, study beginning time, type of NSAIDs, administration time, and sample size.
RESULTS
There were 26 randomized controlled trials (RCTs) with 7954 patients in 31 NSAIDs arms. The pooled incidences were 7.2% for overall PEP (95% confidence interval (CI) 5.9-8.5%), 5.0% for mild PEP (95% CI, 4.0-6.0%), and 1.5% for moderate and severe PEP (0.8-2.3%). PEP rate were higher in patients receiving rectal indomethacin than that of patients receiving rectal diclofenac (7.8% (95% CI, 6.4-9.3%) vs 3.8% (95% CI, 2.2-5.3%), p = 0.009). The PEP rates of high-risk patients and average-risk patients were 8.9% (95% CI, 5.6-12.2%) and 6.4% (95% CI, 5.1-7.6%), respectively (p = 0.160).
CONCLUSIONS
The incidence of PEP was higher in patients receiving 100 mg rectal indomethacin than patients receiving 100 mg diclofenac. The effect of 100 mg diclofenac versus indomethacin on preventing PEP requires further study.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Anti-Inflammatory Agents, Non-Steroidal; Diclofenac; Incidence; Pancreatitis; Indomethacin; Hyperplasia
PubMed: 35941494
DOI: 10.1007/s11605-022-05399-6 -
International Journal of Surgery... 2012Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This... (Review)
Review
BACKGROUND
Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This review summarises the evidence surrounding the natural progression of this condition and potential problems with Niemeier's classification, and proposes a management algorithm for the more complex type II perforation.
METHODS
Data from a retrospective case series and a systematic review were combined. The case series included all patients with gallbladder perforations from 2004 to 2008 at a British teaching hospital. The systematic review searched for gallbladder perforation using the MEDLINE, Embase, Web of Science and Cochrane Library (2011 Issue 4) databases, as well as recent conference abstracts. The outcome data were analysed using SPSS version 15. No adjustments were made for multiple testing.
RESULTS
198 patients (including 19 patients from the present series) with a mean age of 62.1+/-9.7 years and male gender proportion of 55.4% (range 33.3-76.7%) were included. The most common gallbladder perforations were type II (median 46.2%, range 7.4-83.3%), followed by type I (median 40.6%, range 16.7-70.0%) and type III (median 10.1%, range 0-48.1%). Perforation was associated with cholelithiasis in 86.6% (range 78.9-90.6%) of patients, and the overall median mortality rate was 10.8% (range 0-12.5%). Male gender was weakly associated with mortality (p = 0.089) but age (p = 0.877) and cholelithiasis (p = 0.425) were not. Mortality did not vary significantly with perforation type.
CONCLUSIONS
Gallbladder perforation should be reported according to the original Neimeier's classification to avoid heterogeneity in data (e.g. varying rates of perforation types). The algorithm proposed in this study aims to guide the management of complex type II gallbladder perforations to minimise subsequent morbidity and mortality.
Topics: Adult; Aged; Aged, 80 and over; Algorithms; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy; Cholecystitis, Acute; Decision Support Techniques; Female; Gallbladder Diseases; Humans; Male; Middle Aged; Retrospective Studies; Rupture, Spontaneous
PubMed: 22210542
DOI: 10.1016/j.ijsu.2011.12.004 -
Journal of Vascular Surgery Sep 2015Endovascular aortic repair has become increasingly popular the last years for the treatment of abdominal aortic aneurysms (EVAR) and thoracic aortic aneurysms. EVAR is... (Review)
Review
BACKGROUND
Endovascular aortic repair has become increasingly popular the last years for the treatment of abdominal aortic aneurysms (EVAR) and thoracic aortic aneurysms. EVAR is less invasive compared with the classic open approach, related to a decreased immediate postoperative morbidity and mortality. Those beneficial characteristics of EVAR do not come without a cost, since EVAR requires that the patient will be exposed to a significant amount of radiation during preoperative planning, graft placement, and consecutive follow-up. This systematic review examines the periprocedural radiation exposure to patients and staff as well as ways to ameliorate it.
METHODS
A systematic literature search was conducted using the MEDLINE electronic database. All articles reporting radiation exposure to alive humans during EVAR were eligible for review. Only studies publishing numerical data regarding radiation exposure were included in the Results section. Other relevant articles were used for further discussion.
RESULTS
Twenty-four studies, both prospective and retrospective in nature, were included. These studies revealed that the radiation exposure depends on the specific type of procedure, with more complex procedures carrying greater radiation burden. Variations in the positioning and operating of the fluoroscopic unit may significantly alter radiation dose to both patients and staff. There was an apparent lack of education among vascular specialists and trainees in terms of radiation safety awareness. At follow-up, a significant number of patients needed additional procedures, and all required radiographic imaging, further increasing the radiation exposure to alarming levels.
CONCLUSIONS
Every effort should be made to decrease radiation exposure related to endovascular aortic procedures. Attempts must be directed towards maximizing the operator's awareness, welcoming new imaging technology emitting less radiation, and shifting to follow-up strategies that require minimal or no radiation.
Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Aortography; Endovascular Procedures; Humans; Occupational Exposure; Radiation Dosage; Radiation Injuries; Radiation Monitoring; Radiation Protection; Radiography, Interventional; Risk Assessment; Risk Factors
PubMed: 26169014
DOI: 10.1016/j.jvs.2015.05.033 -
Health Technology Assessment... Dec 2018Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important...
Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation.
BACKGROUND
Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA.
OBJECTIVES
To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance.
DATA SOURCES
Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016.
METHODS
We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis.
RESULTS
We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups.
LIMITATIONS
Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data.
CONCLUSIONS
Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases.
FUTURE WORK
Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42016036475.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Aortic Aneurysm, Abdominal; Contrast Media; Cost-Benefit Analysis; Endovascular Procedures; Humans; Quality-Adjusted Life Years; Technology Assessment, Biomedical; Treatment Outcome; Ultrasonography
PubMed: 30543179
DOI: 10.3310/hta22720 -
European Radiology Apr 2022Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is... (Review)
Review
OBJECTIVES
Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is necessary to verify that radiology reporting can benefit from SR. Therefore, the purpose of this systematic review is to explore the level of evidence of structured reporting in radiology. Additionally, this review provides an overview on the current status of SR in radiology.
METHODS
A narrative systematic review was conducted, searching PubMed, Embase, and the Cochrane Library using the syntax 'radiol*' AND 'structur*' AND 'report*'. Structured reporting was divided in SR level 1, structured layout (use of templates and checklists), and SR level 2, structured content (a drop-down menu, point-and-click or clickable decision trees). Two reviewers screened the search results and included all quantitative experimental studies that discussed SR in radiology. A thematic analysis was performed to appraise the evidence level.
RESULTS
The search resulted in 63 relevant full text articles out of a total of 8561 articles. Thematic analysis resulted in 44 SR level 1 and 19 level 2 reports. Only one paper was scored as highest level of evidence, which concerned a double cohort study with randomized trial design.
CONCLUSION
The level of evidence for implementing SR in radiology is still low and outcomes should be interpreted with caution.
KEY POINTS
• Structured reporting is increasingly being used in radiology, especially in abdominal and neuroradiological CT and MRI reports. • SR can be subdivided into structured layout (SR level 1) and structured content (SR level 2), in which the first is defined as being a template in which the reporter has to report; the latter is an IT-based manner in which the content of the radiology report can be inserted and displayed into the report. • Despite the extensive amount of research on the subject of structured reporting, the level of evidence is low.
Topics: Cohort Studies; Humans; Magnetic Resonance Imaging; Radiography; Radiology; Radiology Information Systems
PubMed: 34652520
DOI: 10.1007/s00330-021-08327-5 -
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 -
The Surgeon : Journal of the Royal... Aug 2015Pancreatitis is the most common and serious complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Prevention strategies... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIM
Pancreatitis is the most common and serious complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Prevention strategies targeting risk factors could be important to reduce the rate of post-ERCP pancreatitis. However, the risk factors for post-ERCP pancreatitis (PEP) are still debated. This systematic review and meta-analysis was performed to identify risk factors for PEP.
METHODS
Medline (PubMed and Ovid), Cochrane Central Register of Controlled trials & Database of Systematic Reviews, Embase, Scopus, ScienceDirect, Springer links and WEB OF SCIENCE were searched for published studies in all languages. Inclusion and exclusion criteria were defined a priori. Eighteen probable risk factors were evaluated, and outcomes were expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, (CI)).
RESULTS
When patient-related risk factors were analyzed, the ORs for female gender was 1.46 (95%CI: 1.30-1.64); for previous pancreatitis 2.03 (95%CI: 1.31-3.14); for previous PEP was 2.90 (95%CI: 1.87-4.48); for Sphincter of Oddi dysfunction (SOD) was 2.04 (95%CI: 1.73-2.33) and for Intraductal papillary mucinous neoplasm (IPMN) was 3.01 (95%CI: 1.34-6.77). Four endoscopy-related factors were confirmed: the OR for difficult cannulation was 3.49 (95%CI: 1.364-8.925); for endoscopic sphincterotomy (EST) it was 1.39 (95%CI: 1.09-1.79); for precut sphincterotomy it was 2.25 (95%CI: 1.70_2.96); and for main pancreatic duct injection it was 1.58 (95%CI: 1.21-2.08).
CONCLUSIONS
Female gender, previous pancreatitis, previous PEP, SOD, IPMN, difficult cannulation, EST, precut sphincterotomy and main pancreatic duct injection are risk factors for post-ERCP pancreatitis.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Humans; Pancreatitis; Risk Factors
PubMed: 25547802
DOI: 10.1016/j.surge.2014.11.005