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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 -
Surgical Endoscopy Nov 2022Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or... (Meta-Analysis)
Meta-Analysis
EAES rapid guideline: updated systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on the management of common bile duct stones.
BACKGROUND
Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or intraoperative endoscopic cholangiopancreatography (ERCP), and laparoscopic common bile duct exploration (LCBDE).
OBJECTIVE
To develop evidence-informed, interdisciplinary, European recommendations on the management of common bile duct stones in the context of intact gallbladder with a clinical decision to intervene to both the gallbladder and the common bile duct stones.
METHODS
We updated a systematic review and network meta-analysis of LCBDE, preoperative, intraoperative, and postoperative ERCP. We formed evidence summaries using the GRADE and the CINeMA methodology, and a panel of general surgeons, gastroenterologists, and a patient representative contributed to the development of a GRADE evidence-to-decision framework to select among multiple interventions.
RESULTS
The panel reached unanimous consensus on the first Delphi round. We suggest LCBDE over preoperative, intraoperative, or postoperative ERCP, when surgical experience and expertise are available; intraoperative ERCP over LCBDE, preoperative or postoperative ERCP, when this is logistically feasible in a given healthcare setting; and preoperative ERCP over LCBDE or postoperative ERCP, when intraoperative ERCP is not feasible and there is insufficient experience or expertise with LCBDE (weak recommendation). The evidence summaries and decision aids are available on the platform MAGICapp ( https://app.magicapp.org/#/guideline/nJ5zyL ).
CONCLUSION
We developed a rapid guideline on the management of common bile duct stones in line with latest methodological standards. It can be used by healthcare professionals and other stakeholders to inform clinical and policy decisions.
GUIDELINE REGISTRATION NUMBER
IPGRP-2022CN170.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy, Laparoscopic; GRADE Approach; Network Meta-Analysis; Motion Pictures; Choledocholithiasis; Gallstones; Common Bile Duct
PubMed: 36229556
DOI: 10.1007/s00464-022-09662-4 -
Pancreatology : Official Journal of the... 2015Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and maintenance of pancreatic functions.
METHODS
Medline/PubMed, Embase and Cochrane Library databases were searched to identify studies applying duodenum-preserving total or partial pancreatic-head resection (DPPHRt/p) and reporting short- and long-term outcomes. Twenty-four studies, including 416 patients who underwent DPPHRt/p, were identified for systematic analysis. The meta-analysis was based on 10 prospective controlled and 4 retrospective controlled cohort studies, comparing 293 DPPHRt/p resections with 372 pancreato-duodenectomies (PD).
RESULTS, SYSTEMATIC ANALYSIS
Of 416 patients, 75.7% underwent total and 24.3% partial head resection, while 47.1% included segmentectomy of duodenum and CBD. The most common pathology was cystic neoplasm (65.8%) and endocrine tumors (13.4%). The frequencies of severe postoperative complications of 8.8%, pancreatic fistula of 19.2%, re-operation of 1.7% and hospital mortality of 0.48%, indicate a low level of early post-operative complications.
META-ANALYSIS
DPPHRt/p significantly preserved the level of exocrine (IV = -0.67, 95% CI -0.98 to -0.35, p = 0.0001) and endocrine (IV = 18.20, fixed, 95% CI -0.92 to 25.48, p = 0.0001) pancreatic functions compared to PD when the pre- and postoperative functional status in both groups are analyzed. There were no significant differences between DPPHRt/p and PD in frequency of pancreatic fistula, delayed gastric emptying or hospital mortality.
CONCLUSION
DPPHRt/p for benign neoplasms and neuro-endocrine tumors of the pancreatic head is associated with a low level of early-postoperative complications and a better conservation of exocrine and endocrine functions.
Topics: Common Bile Duct; Duodenum; Humans; Pancreas; Pancreatic Function Tests; Pancreatic Neoplasms
PubMed: 25732271
DOI: 10.1016/j.pan.2015.01.009 -
BMJ Clinical Evidence May 2010Pancreatic cancer is the fourth most common cause of cancer death in higher-income countries, with 5-year survival only 10% even in people presenting with early-stage... (Review)
Review
INTRODUCTION
Pancreatic cancer is the fourth most common cause of cancer death in higher-income countries, with 5-year survival only 10% even in people presenting with early-stage cancer. Risk factors include smoking, high alcohol intake, and dietary factors, while diabetes mellitus and previous pancreatitis may also increase the risk.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical treatments in people with pancreatic cancer considered suitable for complete tumour resection? What are the effects of interventions to prevent pancreatic leak after pancreaticoduodenectomy in people with pancreatic cancer considered suitable for complete tumour resection? What are the effects of adjuvant treatments in people with completely resected pancreatic cancer? What are the effects of interventions in people with non-resectable (locally advanced or advanced) pancreatic cancer? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 46 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: chemoradiotherapy; chemoradiotherapy for non-resectable pancreatic cancer; chemoradiotherapy for resected pancreatic cancer; fibrin glue; fluorouracil-based chemotherapy (adjuvant) for resected pancreatic cancer (with or without surgery); fluorouracil-based chemotherapy for non-resectable pancreatic cancer; fluorouracil-based chemotherapy (systemic); fluorouracil-based combination chemotherapy; fluorouracil-based monotherapy for non-resectable pancreatic cancer; gemcitabine-based chemotherapy (adjuvant) for resected pancreatic cancer; gemcitabine-based chemotherapy (systemic); gemcitabine-based combination chemotherapy; gemcitabine-based monotherapy for non-resectable pancreatic cancer; lymphadenectomy (extended [radical], or standard) in people having pancreaticoduodenectomy; pancreatic duct occlusion; pancreaticoduodenectomy (pylorus-preserving); pancreaticoduodenectomy (Whipple's procedure); pancreaticogastrostomy reconstruction; pancreaticojejunostomy; and somatostatin and somatostatin analogues.
Topics: Fluorouracil; Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus
PubMed: 21729338
DOI: No ID Found -
Gut Oct 2023In up to 20% of patients, the aetiology of acute pancreatitis (AP) remains elusive and is thus called idiopathic. On more detailed review these cases can often be...
OBJECTIVE
In up to 20% of patients, the aetiology of acute pancreatitis (AP) remains elusive and is thus called idiopathic. On more detailed review these cases can often be explained through biliary disease and are amenable to treatment. Findings range from biliary sludge to microlithiasis but their definitions remain fluid and controversial.
DESIGN
A systematic literature review (1682 reports, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines) analysed definitions of biliary sludge and microlithiasis, followed by an online international expert survey (30 endoscopic ultrasound/hepatobiliary and pancreatic experts; 36 items) which led to definitions of both. These were consented by Delphi voting and clinically evaluated in a retrospective cohort of patients with presumed biliary pancreatitis.
RESULTS
In 13% of original articles and 19.2% of reviews, microlithiasis and biliary sludge were used synonymously. In the survey, 41.7% of experts described the term 'sludge' and 'microlithiasis' as identical findings. As a consequence, three definitions were proposed, agreed on and confirmed by voting to distinctly discriminate between biliary sludge (hyperechoic material without acoustic shadowing) and microlithiasis (echorich calculi of ≤5 mm with acoustic shadowing) as opposed to larger biliary stones, both for location in gallbladder and bile ducts. In an initial attempt to investigate the clinical relevance in a retrospective analysis in 177 confirmed cases in our hospital, there was no difference in severity of AP if caused by sludge, microlithiasis or stones.
CONCLUSION
We propose a consensus definition for the localisation, ultrasound morphology and diameter of biliary sludge and microlithiasis as distinct entities. Interestingly, severity of biliary AP was not dependent on the size of concrements warranting prospective randomised studies which treatment options are adequate to prevent recurrence.
Topics: Humans; Pancreatitis; Retrospective Studies; Prospective Studies; Acute Disease; Consensus; Gallstones
PubMed: 37072178
DOI: 10.1136/gutjnl-2022-327955 -
Digestive Endoscopy : Official Journal... Jan 2018The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a... (Review)
Review
BACKGROUND AND AIM
The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight.
METHODS
Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done.
RESULTS
Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n = 87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment.
CONCLUSION
Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.
Topics: Calculi; Cholangiopancreatography, Endoscopic Retrograde; Humans; Lithotripsy; Pancreatic Diseases; Pancreatic Ducts
PubMed: 28656688
DOI: 10.1111/den.12909 -
International Journal of Surgery... Jul 2022To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy.
METHODS
PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to February 26, 2022. Studies comparing outcomes following pancreaticoduodenectomy with or without pancreatic duct stents were included. The primary outcome measured was postoperative pancreatic fistula rate, and secondary outcomes were in-hospital mortality rate, reoperation rate, delayed gastric emptying rate and wound infection rate.
RESULTS
Seven RCTs involving 847 patients met the inclusion criteria. No statistically significant difference between the stent group and non-stent group was detected in the incidence of postoperative pancreatic fistula (RR = 0.85, 95%CI: 0.57-1.26, P = 0.41), in-hospital mortality, reoperation, delayed gastric emptying rate and wound infection. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RR = 0.61, 95%CI: 0.43-0.86, P = 0.005).
CONCLUSIONS
Our preliminary results from this systematic review and meta-analysis revealed that pancreatic duct stents did not reduce the risk of POPF and other complications after pancreaticoduodenectomy compared with no stents. External stents were associated with a reduced POPF rate compared with no stents. Large-scale RCTs are required to assess the effectiveness and assist in clarifying the real role of pancreatic duct stents with respect to the POPF rates after pancreaticoduodenectomy.
Topics: Gastroparesis; Humans; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Stents; Wound Infection
PubMed: 35697324
DOI: 10.1016/j.ijsu.2022.106707 -
Pancreatology : Official Journal of the... 2016The current management of pancreatic mucinous cystic neoplasms (MCN) is defined by the consensus European, International Association of Pancreatology and American... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The current management of pancreatic mucinous cystic neoplasms (MCN) is defined by the consensus European, International Association of Pancreatology and American College of Gastroenterology guidelines. However, the criterion for surgical resection remains uncertain and differs between these guidelines. Therefore through this systematic review of the existing literature we aimed to better define the natural history and prognosis of these lesions, in order to clarify recommendations for future management.
METHODS
A systematic literature search was performed (PubMed, EMBASE, Cochrane Library) for studies published in the English language between 1970 and 2015.
RESULTS
MCNs occur almost exclusively in women (female:male 20:1) and are mainly located in the pancreatic body or tail (93-95%). They are usually found incidentally at the age of 40-60 years. Cross-sectional imaging and endoscopic ultrasound are the most frequently used diagnostic tools, but often it is impossible to differentiate MCNs from branch duct intraductal papillary mucinous neoplasms (BD-IPMN) or oligocystic serous adenomas pre-operatively. In resected MCNs, 0-34% are malignant, but in those less than 4 cm only 0.03% were associated with invasive adenocarcinoma. No surgically resected benign MCNs were associated with a synchronous lesion or recurrence; therefore further follow-up is not required after resection. Five-year survival after surgical resection of a malignant MCN is approximately 60%.
CONCLUSIONS
Compared to other pancreatic tumors, MCNs have a low aggressive behavior, with exceptionally low rates of malignant transformation when less than 4 cm in size, are asymptomatic and lack worrisome features on pre-operative imaging. This differs significantly from the natural history of small BD-IPMNs, supporting the need to differentiate mucinous cyst subtypes pre-operatively, where possible. The findings support the recommendations from the recent European Consensus Guidelines, for the more conservative management of MCNs.
Topics: Humans; Neoplasms, Cystic, Mucinous, and Serous; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 27681503
DOI: 10.1016/j.pan.2016.09.011 -
Journal of Gastrointestinal Surgery :... Oct 2015Postoperative pancreatic fistula (POPF) is one of the most common complications after pancreaticoduodenectomy (PD). The ideal choice of pancreaticojejunostomy (PJ)... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Postoperative pancreatic fistula (POPF) is one of the most common complications after pancreaticoduodenectomy (PD). The ideal choice of pancreaticojejunostomy (PJ) anastomosis remains a matter of debate.
METHODS
A meta-analysis of randomized controlled trials (RCTs) comparing duct-to-mucosa with invagination PJ following PD was performed. Pooled odds ratio (OR) with 95 % confidence intervals (CI) were calculated using fixed-effects or random-effects models.
RESULTS
In total, five RCTs involving 654 patients were included. Meta-analysis revealed no significant difference in POPF rate between the duct-to-mucosa and invagination PJ techniques (OR = 1.23, 95 % CI = 0.78-1.93; P = 0.38). Two of five trials applied the POPF definition proposed by the International Study Group of Pancreatic Surgery (ISGPS). Using this definition, the incidence of clinically relevant POPF was lower in patients undergoing invagination PJ than in those undergoing duct-to-mucosa PJ (OR = 2.94, 95 % CI = 1.31-6.60; P = 0.009). There was no significant difference in terms of delayed gastric emptying, intra-abdominal collection, overall morbidity and mortality, reoperation rate, and length of hospital stay between the two groups.
CONCLUSION
Invagination PJ is not superior to duct-to-mucosa PJ in terms of POPF and other complications but appears to reduce clinically relevant POPF. Further well-designed RCTs that use ISGPS definition are still required before strong evidence-based recommendations can be formulated.
Topics: Gastric Emptying; Humans; Intestinal Mucosa; Length of Stay; Pancreatectomy; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Recovery of Function; Reoperation
PubMed: 26264363
DOI: 10.1007/s11605-015-2913-1 -
International Journal of Surgery... Jul 2023The best approach for treating benign or low-grade malignant lesions localized in the pancreatic neck or body remains debatable. Conventional pancreatoduodenectomy and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The best approach for treating benign or low-grade malignant lesions localized in the pancreatic neck or body remains debatable. Conventional pancreatoduodenectomy and distal pancreatectomy (DP) are associated with a risk of impairment of pancreatic function at long-term follow-up. With advances in technology and surgical skills, the use of central pancreatectomy (CP) has gradually increased.
OBJECTIVES
The objective was to compare the safety, feasibility, and short-term and long-term clinical benefits of CP and DP in matched cases.
METHODS
The PubMed, MEDLINE, Web of Science, Cochrane, and EMBASE databases were systematically searched to identify studies published from database inception to February 2022 that compared CP and DP. This meta-analysis was performed using R software.
RESULTS
Twenty-six studies matched the selection criteria, including 774 CP and 1713 DP cases. CP was significantly associated with longer operative time ( P <0.0001), less blood loss ( P <0.01), overall and clinically relevant pancreatic fistula ( P <0.0001), postoperative hemorrhage ( P <0.0001), reoperation ( P =0.0196), delayed gastric emptying ( P =0.0096), increased hospital stay ( P =0.0002), intra-abdominal abscess or effusion ( P =0.0161), higher morbidity ( P <0.0001) and severe morbidity ( P <0.0001) but with a significantly lower incidence of overall endocrine and exocrine insufficiency ( P <0.01), and new-onset and worsening diabetes mellitus ( P <0.0001) than DP.
CONCLUSIONS
CP should be considered as an alternative to DP in selected cases such as without pancreatic disease, length of the residual distal pancreas is more than 5 cm, branch-duct intraductal papillary mucinous neoplasms, and a low risk of postoperative pancreatic fistula after adequate evaluation.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Retrospective Studies; Pancreas; Pancreatic Neoplasms; Postoperative Complications
PubMed: 37300889
DOI: 10.1097/JS9.0000000000000326