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Surgical Laparoscopy, Endoscopy &... Feb 2016The introduction of endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ES) has changed the treatment of choledocholithiasis. An increasing... (Review)
Review
The introduction of endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ES) has changed the treatment of choledocholithiasis. An increasing number of young patients are requiring ES, and this raises concern regarding any potential long-term complications arising from irreversibly altering the anatomy of the sphincter of Oddi. In particular, concern has been raised regarding the risk of late cholangiocarcioma. A review was performed evaluating the relationship between ES for benign disease and the subsequent development of late complications, including biliary tract malignancy, the formation of primary duct stones, and recurring cholangitis. A systematic review of articles published between 1970 and 2013 was undertaken. Current evidence shows that ES is a safe and effective treatment for common bile duct stones. The long-term risk of subsequent cholangiocarcinoma has not been convincingly proven although in many of these studies the follow-up period was inadequate. There does appear to be an associated increased incidence of cholangiocarcinomas following sphincterotomy although this is not proven to be causative. If there is an increased risk of cholangiocarcinoma following ES, it is likely to be small in western populations. However, until longer follow-up studies are published, it may be prudent to avoid ES in the very young.
Topics: Bile Duct Neoplasms; Cholangiocarcinoma; Cholangiopancreatography, Endoscopic Retrograde; Cholangitis; Choledocholithiasis; Gallstones; Humans; Postoperative Complications; Recurrence; Sphincterotomy, Endoscopic
PubMed: 26679684
DOI: 10.1097/SLE.0000000000000226 -
Journal of Surgical Oncology Nov 2022Germline BRCA1/2 mutations lead to malfunction of DNA damage repair pathways and predispose to pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to... (Meta-Analysis)
Meta-Analysis Review
Germline BRCA1/2 mutations lead to malfunction of DNA damage repair pathways and predispose to pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to synthesise the available research on this topic. Four studies reporting risk ratio (RR) were included in the final meta-analysis to minimise misrepresenting our results by combining separate risk estimates. Our meta-analysis revealed a statistically significant increased risk of PDAC in BRCA carriers overall (RR: 2.65, 95% confidence interval: 1.43-4.91, p = 0.002).
Topics: BRCA1 Protein; BRCA2 Protein; Carcinoma, Pancreatic Ductal; Germ-Line Mutation; Humans; Mutation; Pancreatic Ducts; Pancreatic Neoplasms
PubMed: 35770919
DOI: 10.1002/jso.26994 -
Translational Gastroenterology and... 2022Radiofrequency ablation (RFA) has been used to treat various abdominal tumors including pancreatic tumors. Multiple approaches such as laparoscopic, open, and...
BACKGROUND
Radiofrequency ablation (RFA) has been used to treat various abdominal tumors including pancreatic tumors. Multiple approaches such as laparoscopic, open, and percutaneous have been used for pancreatic tissue ablation. More recently, endoscopic ultrasound (EUS)-guided RFA has emerged as a new technique for pancreatic tissue ablation. The role of EUS-RFA in management of pancreatic lesions is still not well-established. In this study, our aim is to assess efficacy and safety of EUS-RFA for management of pancreatic lesions.
METHODS
MEDLINE, Scopus, and Cochrane Library databases were searched to identify studies reporting EUS-RFA of pancreatic lesions with outcomes of interest. Studies with <5 patients were excluded. Clinical success was defined as symptom resolution, decrease in tumor size, and/or evidence of necrosis on radiologic imaging. Efficacy was assessed by the pooled clinical response rate whereas safety was assessed by the pooled adverse events rate. Heterogeneity was assessed using I. Pooled estimates and the 95% CI were calculated using random-effect model.
RESULTS
Ten studies (5 retrospective and 5 prospective) involving 115 patients with 125 pancreatic lesions were included. 152 EUS-RFA procedures were performed. The lesions comprised of 37.6% non-functional neuroendocrine tumors (NFNETs), 15.4% were insulinomas, 26.5% were pancreatic cystic neoplasms (PCNs), and 19.7% were pancreatic adenocarcinomas. The majority were present in the pancreatic head (40.2%), 38.3% in the body, 11.2% in the tail, and 10.3% in the uncinate process. Pooled overall clinical response rate was 88.9% (95% CI: 82.4-93.7, I=38.1%). Pooled overall adverse events rate was 6.7% (95% CI: 3.4-11.7, I=34.0%). The most common complication was acute pancreatitis (3.3%) followed by pancreatic duct stenosis, peripancreatic fluid collection, and ascites (2.8%) each. Only one case of perforation was reported with pooled rate of (2.1%).
DISCUSSION
This study demonstrates that EUS-RFA is an effective treatment modality for pancreatic lesions, especially functional neuroendocrine tumors such as insulinomas.
PubMed: 35892058
DOI: 10.21037/tgh-20-84 -
Digestive Diseases and Sciences May 2021Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not...
BACKGROUND
Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis.
METHODS
A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted.
RESULTS
We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP.
CONCLUSIONS
This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.
Topics: Amylases; Biomarkers; Cholangiopancreatography, Endoscopic Retrograde; Cholangiopancreatography, Magnetic Resonance; Clinical Enzyme Tests; Endosonography; Humans; Pancreatic Ducts; Pancreatitis; Predictive Value of Tests; Reproducibility of Results; Secretin; Severity of Illness Index
PubMed: 32594462
DOI: 10.1007/s10620-020-06413-0 -
Annals of Surgical Oncology Feb 2022The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to... (Meta-Analysis)
Meta-Analysis Review
Imaging Features for Predicting High-Grade Dysplasia or Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Systematic Review and Meta-Analysis.
BACKGROUND
The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to determine imaging features and their diagnostic accuracy for predicting high-grade dysplasia (HGD)/malignancy in BD-IPMN, including mixed type.
METHODS
The PubMed, Embase, and Cochrane databases were searched, and data were extracted from relevant studies. As the main diagnostic accuracy index, diagnostic odds ratios (DORs) of imaging features for diagnosing HGD/malignancy in BD-IPMNs were pooled using the random-effects model. A bivariate random-effects approach was used to construct summary receiver operating characteristic curves for sensitivity and specificity estimation.
RESULTS
The pooled DOR was the highest for the enhanced solid component/mural nodule (MN) (DOR, 12.21; 95 % confidence interval [CI], 6.14-24.27), followed by a main pancreatic duct (MPD) diameter of 10 mm or greater (DOR, 7.93; 95 % CI, 3.02-20.83), solid component (DOR, 4.85; 95 % CI, 2.49-9.42), lymphadenopathy (DOR, 4.84; 95 % CI, 1.11-21.06), MN (DOR, 4.48; 95 % CI, 3.15-6.39), an MPD diameter of 5 mm or greater (DOR, 3.69; 95 % CI, 2.62-5.19), abrupt change in MPD caliber with distal pancreatic atrophy (DOR, 2.65; 95 % CI, 1.66-4.24), thickened/enhancing walls (DOR, 2.38; 95 % CI, 1.57-3.60), and cyst size of 3 cm or larger (DOR, 1.98; 95 % CI, 1.48-2.64). The largest area under the curve (0.89 and 0.95, respectively) and high specificity (0.95 and 0.98, respectively) also were found for enhanced solid component/MN and an MPD diameter of 10 mm or greater, albeit with low sensitivity (0.38 and 0.14, respectively).
CONCLUSIONS
The aforementioned imaging features could aid in predicting HGD/malignancy of BD-IPMN. Furthermore, enhanced solid component/MN and an MPD diameter of 10 mm or greater were the most important predictors of HGD/malignancy in BD-IPMN and should be considered as indications for surgery.
Topics: Adenocarcinoma, Mucinous; Carcinoma, Pancreatic Ductal; Humans; Pancreas; Pancreatic Ducts; Pancreatic Neoplasms; Retrospective Studies
PubMed: 34554343
DOI: 10.1245/s10434-021-10662-2 -
HPB : the Official Journal of the... Dec 2019The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy).
METHODS
A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases.
RESULTS
Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD -115.8 min, CI -142.2 to -89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection.
CONCLUSION
EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.
Topics: Exocrine Pancreatic Insufficiency; Gastric Emptying; Humans; Length of Stay; Neoplasm Recurrence, Local; Operative Time; Pancreatectomy; Pancreatic Fistula; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Postoperative Hemorrhage
PubMed: 31153837
DOI: 10.1016/j.hpb.2019.04.015 -
Acta Cytologica 2023The WHO Reporting System for Pancreaticobiliary Cytopathology revised the Papanicolaou Society of Cytopathology guidelines in alignment with the WHO classification of... (Meta-Analysis)
Meta-Analysis
Diagnostic Performance of Bile Duct Brush Cytology with Risk of Malignancy of Standardized Categories in the Wake of World Health Organization Reporting System for Pancreaticobiliary Cytopathology: An Updated Systematic Review and Meta-Analysis.
INTRODUCTION
The WHO Reporting System for Pancreaticobiliary Cytopathology revised the Papanicolaou Society of Cytopathology guidelines in alignment with the WHO classification of digestive system tumors, 5th edition. The current systematic review and meta-analysis have been conducted to accurately assess the performance of bile duct brush cytology and report the risk of malignancy (ROM) of each standard category by following the guidelines of diagnostic test accuracy meta-analysis.
METHODS
Medline/Pubmed and Cochrane databases were searched till June 8, 2023, with a strategy that included target site (pancreaticobiliary and related terms), diagnostic method (bile duct brushing and related terms), and keywords for diagnostic performance (for Cochrane database). Inclusion criteria included studies that have assessed bile duct cytology (BDC) for pancreaticobiliary duct stricture with a sample size of over 50, provided cytological diagnoses similar to the WHO system with details to deduce true positives, true negatives, false positives, and false negatives through subsequent final diagnoses (benign vs. malignant). The exclusion criteria were the fewer sample size, assessment through other cytological categories, limited data, and clinical setting. Two authors independently reviewed the result of the search strategy. The quality of the selected articles was assessed by the QUADAS-2 tool. Bivariate random-effects model was used to get the pooled sensitivity and specificity. Heterogeneity across studies was assessed using I-squared statistics, and potential sources were found using meta-regression. Pooled and a range of ROM in each category was analyzed.
RESULTS
Thirteen studies were included with 4,398 bile duct brushings. The pooled sensitivity is 0.437 (95% CI: 0.371-0.504), and the pooled specificity is 0.972 (95% CI: 0.943-0.987). The ROM in various categories are as follows: inadequate/nondiagnostic: 23-100% (pooled: 50.15%), benign/negative for malignancy: 22-70% (38%), atypical: 0-95% (66%), suspicious for malignancy: 74-100% (89%), malignant: 91-100% (98%).
CONCLUSION
Even with standard cytological categories, the sensitivity of BDC remains low. The review has analyzed and discussed potential causes of heterogeneity that will be helpful for future diagnostic studies.
Topics: Humans; Bile Ducts; Cytodiagnosis; Bile Duct Neoplasms; Pancreatic Neoplasms; Sensitivity and Specificity
PubMed: 37879315
DOI: 10.1159/000534764 -
Annals of Surgery Feb 2007Comparison of effectiveness between the pylorus-preserving pancreaticoduodenectomy ("pylorus-preserving Whipple" [PPW]) and the classic Whipple (CW) procedure. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Comparison of effectiveness between the pylorus-preserving pancreaticoduodenectomy ("pylorus-preserving Whipple" [PPW]) and the classic Whipple (CW) procedure.
METHODS
A systematic literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed to identify all eligible articles. Randomized controlled trials (RCTs) comparing PPW versus CW for periampullary and pancreatic carcinoma were eligible for inclusion. The methodologic quality of included studies was evaluated independently by 2 authors. Quantitative data on perioperative parameters (blood loss, transfusion, operation time, and length of hospital stay), mortality, morbidity, and survival were extracted from included studies for meta-analysis. Pooled estimates of overall treatment effect were calculated using a random effects model.
RESULTS
In total, 1235 abstracts were retrieved and checked for eligibility and 6 RCTs finally included. The critical appraisal revealed vast heterogeneity with respect to methodologic quality and outcome parameters. The comparison of overall in-hospital mortality (odds ratio, 0.49; 95% CI, 0.17 to 1.40; P = 0.18), morbidity (odds ratio 0.89; 95% CI, 0.48 to 1.62; P = 0.69), and survival (hazard ratio, 0.74; 95% CI, 0.52 to 1.07; P = 0.11) showed no significant difference. However, operating time (weighted mean difference, -68.26 minutes; 95% CI, -105.70 to -30.83; P = 0.0004), and intraoperative blood loss (weighted mean difference, -766 mL; 95% CI, -965.26 to -566.74; P = 0.00001) were significantly reduced in the PPW group.
CONCLUSION
Hence, in the absence of relevant differences in mortality, morbidity, and survival, the PPW seems to be as effective as the CW. Given obvious clinical and methodological interstudy heterogeneity, efforts should be intensified in the future to perform high quality RCTs of complex surgical interventions on the basis of well defined outcome parameters.
Topics: Ampulla of Vater; Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Randomized Controlled Trials as Topic; Survival Rate; Treatment Outcome
PubMed: 17245171
DOI: 10.1097/01.sla.0000242711.74502.a9 -
Annals of Gastroenterology 2021The American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF),...
BACKGROUND
The American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF), whereas the American College of Gastroenterology recommends EUS for ≥1 HRF. This systematic review and meta-analysis compared the diagnostic accuracy of using ≥1 vs. ≥2 HRF for assessing the risk of advanced neoplasia (AN) and performing EUS in PCL.
METHODS
An electronic database search was performed for eligible studies. AN was defined as pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm or mucinous cystadenoma with high-grade dysplasia, pancreatic intraepithelial neoplasia and pancreatic neuroendocrine tumors. HRF included cyst size ≥3 cm, solid component, and dilated pancreatic duct ≥5 mm. The primary outcome was the sensitivity and specificity of using ≥1 vs. ≥2 HRF as an indication for EUS to detect AN in PCL.
RESULTS
Of 38 studies initially screened, 8 were included in the final analysis. Seven studies assessed the accuracy of ≥2 HRF and 4 studies assessed ≥1 HRF. The pooled sensitivity, specificity, positive and negative predictive values of EUS for detecting AN were 41.7% (95% confidence interval 19.5-67.8%), 90.8% (81.9-95.5%), 30.4% (19.4-44.2%) and 94.3% (89.6-97.0%) with ≥2HRFs, and 77.1% (66.1-85.3%), 72.7% (50.4-87.5%), 17.95% (10.3-29.4%), 98.1% (90.8-99.6%), respectively, with ≥1 HRF.
CONCLUSION
Performing EUS for PCL with ≥1 HRF could offer greater sensitivity in detecting AN compared to ≥2 HRF, with a similar negative predictive value.
PubMed: 34475747
DOI: 10.20524/aog.2021.0630 -
Scandinavian Journal of Gastroenterology Oct 2016Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded... (Review)
Review
BACKGROUND
Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.
METHODS
A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.
RESULTS
A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.
CONCLUSIONS
Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
Topics: Digestive System Surgical Procedures; Drainage; Humans; Morbidity; Pancreas; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27216233
DOI: 10.3109/00365521.2016.1169317