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Gastrointestinal Endoscopy Jul 2023The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs).
METHODS
The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality.
RESULTS
One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48).
CONCLUSIONS
The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.
Topics: Humans; Incidence; Cholangiopancreatography, Endoscopic Retrograde; Randomized Controlled Trials as Topic; Pancreatitis; Stents
PubMed: 37004815
DOI: 10.1016/j.gie.2023.03.023 -
Digestive and Liver Disease : Official... Jan 2024Single use duodenoscopes were developed to reduce the risk of infection transmission from contaminated reusable duodenoscopes. To this end, we examined various biliary... (Meta-Analysis)
Meta-Analysis Review
Cannulation rates and technical performance evaluation of commericially available single-use duodenoscopes for endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis.
BACKGROUND
Single use duodenoscopes were developed to reduce the risk of infection transmission from contaminated reusable duodenoscopes. To this end, we examined various biliary interventions using single use duodenoscopes in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).
METHODS
Medline, Embase, Scopus, and Cochrane databases were searched from inception through Aug 2022 to identify studies reporting on the performance of single use duodenoscopes for ERCP.
RESULTS
Seven articles were included in the final analysis that included 642 patients (318 males). The Exalt Model D duodenoscope was used in most cases (88.8%) followed by the aScope Duodeno (11.2%) for ERCP. Most ERCPs had a complexity grade of 2 (n = 303) and 3 (n = 198). The pooled cumulative rate of successful cannulation was 95% (95% Confidence Interval (CI): 93-96%, I2=0%, P = 0.46). Sphincterotomy was successfully performed in all cases. The pooled cumulative rate of PEP was 2% (95% CI: 0.4-3.4%, I2=0%, P = 0.80). The pooled cumulative rate of total adverse events was 7% (95% CI: 4-10%, I2=47%, P = 0.08).
CONCLUSIONS
The results of this systematic review and meta-analysis show that single use duodenoscopes are associated with high cannulation rates, technical performance, and safety profile.
Topics: Male; Humans; Cholangiopancreatography, Endoscopic Retrograde; Duodenoscopes; Catheterization
PubMed: 37003844
DOI: 10.1016/j.dld.2023.02.022 -
Journal of Medical Case Reports Mar 2023Neuroendocrine tumors of the minor papilla are very rare, and only 20 cases have been reported in the literature. Neuroendocrine carcinoma of the minor papilla with...
BACKGROUND
Neuroendocrine tumors of the minor papilla are very rare, and only 20 cases have been reported in the literature. Neuroendocrine carcinoma of the minor papilla with pancreas divisum has not been reported previously, making this the first reported case. Neuroendocrine tumors of the minor papilla have been reported in association with pancreas divisum in about 50% of cases reported in the literature. We herein present our case of neuroendocrine carcinoma of the minor papilla with pancreas divisum in a 75-year-old male with a systematic literature review of the previous 20 reports of neuroendocrine tumors of the minor papilla.
CASE PRESENTATION
A 75-year-old Asian man was referred to our hospital for evaluation of dilation of the main pancreatic duct noted on abdominal ultrasonography. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed a dilated dorsal pancreatic duct, which was not connected to the ventral pancreatic duct; however, it opened to the minor papilla, indicating pancreas divisum. The common bile duct had no communication with the pancreatic main duct and opened to the ampulla of Vater. A contrast-enhanced computed tomography scan showed a 12-mm hypervascular mass near the ampulla of Vater. Endoscopic ultrasonography showed a defined hypoechoic mass in the minor papilla with no invasion. The biopsies performed at the previous hospital found adenocarcinoma. The patient underwent a subtotal stomach-preserving pancreaticoduodenectomy. The pathological diagnosis was neuroendocrine carcinoma. At the 15-year follow-up visit, the patient was doing well with no evidence of tumor recurrence.
CONCLUSION
In our case, because the tumor was discovered during a medical check-up relatively early in the course of disease, the patient was doing well at the 15-year follow-up visit, with no evidence of tumor recurrence. Diagnosing a tumor of the minor papilla is very difficult because of the relatively small size and submucosal location. Carcinoids and endocrine cell micronests in the minor papilla occur more frequently than generally thought. It is very important to include neuroendocrine tumors of the minor papilla in the differential diagnosis of patients with recurrent pancreatitis or pancreatitis of unknown cause, especially for patients with pancreas divisum.
Topics: Male; Humans; Aged; Pancreas; Pancreas Divisum; Neoplasm Recurrence, Local; Pancreatic Ducts; Cholangiopancreatography, Endoscopic Retrograde; Pancreatitis; Carcinoma, Neuroendocrine
PubMed: 36973791
DOI: 10.1186/s13256-023-03828-x -
JSLS : Journal of the Society of... 2023Routine intraoperative cholangiography (IOC) for laparoscopic cholecystectomy (LC) remains controversial. The primary outcomes of this meta-analysis were detection rates... (Meta-Analysis)
Meta-Analysis
BACKGROUND/OBJECTIVES
Routine intraoperative cholangiography (IOC) for laparoscopic cholecystectomy (LC) remains controversial. The primary outcomes of this meta-analysis were detection rates of choledocholithiasis, bile duct injuries (BDI), and missed stones in LCs.
METHODS
A systematic literature search was conducted for the time period January 1, 1990 to July 31, 2022. Some studies reported LCs with conversion to open therefore subgroup analysis in BDI rates was performed for studies which included LCs with and without conversion to open. Studies including primary open cholecystectomies were excluded. I statistics were used for heterogeneity analysis.
RESULTS
Fourteen studies involving 440659 patients were included. In studies comparing routine and selective IOC policies in LC, 61.1% of patients underwent routine IOC; 38.9% underwent selective IOC. In studies comparing IOC to no IOC in LC, 17.3% of patients had IOC; 82.7% did not. Between the selective and routine IOC groups there was no difference in choledocholithiasis detection rate (odds ratio [OR] = 1.33, p = 0.20, 95% confidence interval [CI] = 0.86 - 2.04), no difference in the rate of missed stones (OR = 1.59, p = 0.58; 95% CI = 0.31 - 8.29), and no difference in BDI rates in selective compared to routine IOC (OR = 0.92, p = 0.92; 95% CI = 0.20 - 4.22). There was no difference in the BDI detection rates in LC with and without IOC (OR = 1.12, p = 0.77; 95% CI = 0.52 - 2.38).
CONCLUSION
This is the largest meta-analysis on this topic to date. There was no statistically significant difference in choledocholithiasis detection, missed stones, or BDI rates in the analyzed groups.
Topics: Humans; Cholecystectomy, Laparoscopic; Choledocholithiasis; Cholangiography; Cholecystectomy; Odds Ratio
PubMed: 36923161
DOI: 10.4293/JSLS.2022.00093 -
ANZ Journal of Surgery May 2023Duodenal diverticulum occurs in approximately 20% of the population and can lead to life-threatening complications such as perforation. Most perforations are secondary...
BACKGROUND
Duodenal diverticulum occurs in approximately 20% of the population and can lead to life-threatening complications such as perforation. Most perforations are secondary to diverticulitis, with iatrogenic causes being exceptionally rare. This systematic review explores the aetiology, prevention and outcomes of iatrogenic perforation of duodenal diverticulum.
METHODS
A systematic review was performed according to the PRISMA guidelines. Four databases were searched, including Pubmed, Medline, Scopus and Embase. The primary data extracted were clinical findings, type of procedure, prevention and management of perforation and outcomes.
RESULTS
Forty-six studies were identified, of which 14 articles met inclusion criteria and comprised 19 cases of iatrogenic duodenal diverticulum perforation. Four cases identified duodenal diverticulum pre-intervention, nine were identified peri-intervention, and the remainder were identified post-intervention. Perforation secondary to endoscopic retrograde cholangiopancreatography (n = 8) was most common, followed by open and laparoscopic surgery (n = 5), gastroduodenoscopy (n = 4) and other (n = 2). Operative management with diverticulectomy was the most frequent treatment (63%). Iatrogenic perforation was associated with 50% morbidity and 10% mortality.
CONCLUSION
Iatrogenic perforation of duodenal diverticulum is exceptionally rare and associated with high morbidity and mortality. There are limited guidelines surrounding standard perioperative steps to prevent iatrogenic perforations. A review of preoperative imaging helps identify potential aberrant anatomy, such as a duodenal diverticulum, to allow for recognition and prompt management initiation in the event of perforation. Intraoperative recognition and immediate surgical repair are safe options for this complication.
Topics: Humans; Duodenal Ulcer; Cholangiopancreatography, Endoscopic Retrograde; Gastroscopy; Diverticulum; Iatrogenic Disease; Intestinal Perforation
PubMed: 36881513
DOI: 10.1111/ans.18376 -
Endoscopy Sep 2023BACKGROUND : Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is critical for supporting learning and documenting attainment of skill....
BACKGROUND : Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is critical for supporting learning and documenting attainment of skill. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated. METHODS : We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively. RESULTS : From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one for simulated ERCP, and one for simulated and clinical ERCP. Validity evidence scores ranged from 2 to 12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence, with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality (maximum score 13.5) was strong, with scores ranging from 10 to 12.5. CONCLUSIONS : The BESAT, ERCP DOPS, and TEESAT had strong validity evidence compared with other assessments. Integrating tools into training may help drive learners' development and support competency decision making.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Clinical Competence; Educational Measurement; Education, Medical, Graduate; Learning Curve; Reproducibility of Results
PubMed: 36822219
DOI: 10.1055/a-2041-7546 -
European Journal of Medical Research Feb 2023Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on... (Review)
Review
INTRODUCTION
Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies.
METHODS
We used the MESH terms "appendicitis" AND "situs inversus" AND/OR "gut malrotation" to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data.
RESULTS
We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener's syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition.
CONCLUSION
Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.
Topics: Humans; Female; Male; Child; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Radiography; Acute Disease; Diagnosis, Differential
PubMed: 36805741
DOI: 10.1186/s40001-023-01059-w -
Annals of Medicine Dec 2022The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes.
CONCLUSIONS
Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement.
METHODS
A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity.
RESULTS
Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, = .64; and OR = 2.3, 95%CI: 0.68-7.76, = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, = .07).
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cholestasis; Constriction, Pathologic; Pancreatitis; Plastics; Stents; Treatment Outcome
PubMed: 36799364
DOI: 10.1080/07853890.2022.2105395 -
Surgical Endoscopy Jun 2023In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP)... (Meta-Analysis)
Meta-Analysis Review
Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis.
BACKGROUND
In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care.
METHODS
A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP.
RESULTS
A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96% (95% CI 92-97.6, I = 0), and clinical success was 91% (85-95, I = 0). Pooled rate of all adverse events with EDGE was 17% (14-24.6, I = 32%). On sub-group analysis, these included failure of fistula closure 17% (10-25.5, I = 48%), stent migration 7% (4-12, I = 51%), bleeding 5% (3.2-7.9, I = 0), post-EDGE weight gain 4% (2-9, I = 0), perforation 4% (2.1-5.8, I = 0), and post-ERCP pancreatitis 2% (1-5, I = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85-1.17, p = 0.95) and E-ERCP (100% vs. 66%; RR, 1.26; CI, 0.99-1.6, p = 0.06). No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28-1.35, p = 0.52) and E-ERCP (9.6% vs. 16%; RR, 0.61; CI, 0.28-1.35, p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001).
CONCLUSION
Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Gastric Bypass; Endosonography; Endoscopy, Gastrointestinal; Pancreatitis; Retrospective Studies
PubMed: 36792784
DOI: 10.1007/s00464-023-09926-7 -
Langenbeck's Archives of Surgery Jan 2023The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography...
BACKGROUND
The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) has been the main approach for managing choledocholithiasis during pregnancy, but recent progress in laparoscopic bile duct exploration (LBDE) has demonstrated this technique as a safe and effective alternative option.
METHODS
A retrospective multicenter study of all patients who underwent LBDE during pregnancy from five centers with proven experience in LBDE between January 2010 and June 2020 was performed. The primary endpoint was to analyze the role of LBDE during pregnancy and to further characterize its position as a safe and effective alternative for the management of choledocholithiasis. A systematic review of the published literature relating to LBDE during pregnancy until February 2022 was also performed.
RESULTS
Five institutions reported performing LBDE during pregnancy in 8 patients. Median surgical time was 75 min (range: 60-140 min). The bile duct was cleared successfully in all patients, and the median hospital stay was 2 days (range: 1-3 days). The literature review identified a total of 7 patients with a successful CBD clearance rate of 86%. There were no major maternal, fetal, or pregnancy-related complications in any of the total 15 patients included. The symptomatic common bile duct lithiasis with deranged liver function tests was the most frequent indication (n=7).
CONCLUSION
LBDE during pregnancy appears to be safe and effective. More evidence reporting outcomes of LBDE during pregnancy is needed before any strong recommendations can be made.
Topics: Humans; Pregnancy; Female; Choledocholithiasis; Cholecystectomy, Laparoscopic; Laparoscopy; Bile Ducts; Cholangiopancreatography, Endoscopic Retrograde; Retrospective Studies; Multicenter Studies as Topic
PubMed: 36662260
DOI: 10.1007/s00423-023-02793-9