-
Therapeutic Advances in... 2019Endoscopic ultrasound-guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze...
BACKGROUND
Endoscopic ultrasound-guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze the efficacy and safety of cystogastrostomy via a meta-analysis of the literature.
METHODS
We performed a systematic search of PubMed and Medline databases for studies published from January 2005 to May 2018. We included randomized controlled trials along with retrospective and prospective observational studies reporting endoscopic ultrasound-guided cystogastrostomy stent placement for peripancreatic fluid collections. The primary outcome for our meta-analysis was complete peripancreatic fluid collection resolution on imaging. Our secondary outcomes included comparative efficacy and safety of the procedure for pseudocysts and walled-off pancreatic necrosis using metal and plastic stents.
RESULTS
Seventeen articles involving 1708 patients met our inclusion criteria for meta-analysis. Based upon the random effects model, the pooled technical success rate of cystogastrostomy was 88% (95% confidence interval = 83-92 with = 85%). There was no difference in the technical success rate between pancreatic pseudocysts and walled-off pancreatic necrosis (91% and 86%, respectively = nonsignificant). The adverse event rates for metal and plastic stents were equivalent (14% and 18%, respectively, = nonsignificant).
CONCLUSION
Endoscopic ultrasound-guided cystogastrostomy stents are effective in the treatment of pancreatic pseudocysts and walled-off pancreatic necrosis. We found no difference in technical success or adverse event rates of drainage based on peripancreatic fluid collection type or stent used.
PubMed: 31192314
DOI: 10.1177/2631774519843400 -
World Neurosurgery Sep 2019No widely accepted gold standard for diagnosis of shunt infection exists, with definitions variable among clinicians and publications. This article summarizes the...
BACKGROUND
No widely accepted gold standard for diagnosis of shunt infection exists, with definitions variable among clinicians and publications. This article summarizes the utility of commonly used diagnostic tools and provides a comprehensive review of optimal measures for diagnosis.
METHODS
A query of PubMed was performed extracting articles related to shunt infection in children. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, resulting in 1756 articles related to shunt infection, 49 of which ultimately met inclusion criteria.
RESULTS
Of the 49 articles included in the analysis, 9 did not define infection, 9 used culture alone, 9 used cultures and/or symptomatology, and 4 used a combination of cultures, cerebral spinal fluid (CSF) pleocytosis and symptomatology. The remainder of the studies used definitions from the Centers for Disease Control and Prevention (n = 2) and the Hydrocephalus Clinical Research Network (n = 2) or borrowed elements from these definitions. Variation in definition stems from the lack of sensitivity and specificity of commonly used signs, symptoms, and tests. Shunt tap alone is considered half as sensitive as hardware culture. Fever upon presentation was present in 16% to 42% of cases. CSF pleocytosis combined with fever has a sensitivity of 82% and specificity of 99%. CSF eosinophilia, lactic acid, serum anti-Staphylococcus epidermidis titer, procalcitonin, and C-reactive protein are non-specific and their utility is not well established.
CONCLUSIONS
The definition of shunt infection is variable across studies, with CSF culture and/or symptomatology being the most commonly utilized parameters.
Topics: Cerebrospinal Fluid Shunts; Child; Female; Humans; Hydrocephalus; Infections; Male; Postoperative Complications
PubMed: 31100520
DOI: 10.1016/j.wneu.2019.05.057 -
Revista Espanola de Enfermedades... Jun 2019the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND AND AIM
the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute pancreatitis will develop infected necrotizing pancreatitis (INP), which is the leading cause of high mortality in the late phase. There is currently no consensus with regard to the use of endoscopic or minimally invasive surgery as the first-line therapy of choice for INP. However, more clinical research with regard to the superiority of an endoscopic approach has been recently published. Therefore, we conducted a systematic review and meta-analysis to determine which of the two treatments leads to a better prognosis.
METHODS
four databases (Medline, SINOMED, EMBASE and Cochrane Library) were searched for eligible studies from 1980 to 2018, comparing endoscopic and minimally invasive surgery for INP.
RESULTS
two randomized controlled trials (RCTs) and seven clinical cohort studies were included. After the analysis of data amenable to polling, significant advantages were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001). No marked differences were found in terms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency.
CONCLUSION
compared with minimally invasive surgery, an endoscopic approach evidently improved short-term outcomes for infected necrotizing pancreatitis, including pancreatic fistula and the length of hospital stay. Furthermore, relevant multicenter RCTs are eager to validate these findings.
Topics: Endoscopy, Digestive System; Humans; Minimally Invasive Surgical Procedures; Pancreatitis, Acute Necrotizing
PubMed: 31021167
DOI: 10.17235/reed.2019.5792/2018 -
Medicine Feb 2019This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP). (Meta-Analysis)
Meta-Analysis
OBJECTIVE
This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP).
METHODS
The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization.
RESULTS
There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001).
CONCLUSION
There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.
Topics: Cost Savings; Drainage; Endoscopy; Humans; Length of Stay; Pancreatic Pseudocyst; Postoperative Complications; Recurrence; Treatment Outcome
PubMed: 30813129
DOI: 10.1097/MD.0000000000014255 -
Expert Review of Gastroenterology &... Dec 2018Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally...
Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.
Topics: Acute Disease; Cholangiopancreatography, Endoscopic Retrograde; Drainage; Endosonography; Humans; Pancreatic Pseudocyst; Pancreatitis; Pancreatitis, Acute Necrotizing; Prosthesis Design; Stents; Syndrome; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Interventional
PubMed: 30791791
DOI: 10.1080/17474124.2018.1537781 -
World Neurosurgery May 2019Perforation of a solid visceral organ and subsequent development of a cerebrospinal fluid pseudocyst is a rare complication of ventriculoperitoneal shunts.
BACKGROUND
Perforation of a solid visceral organ and subsequent development of a cerebrospinal fluid pseudocyst is a rare complication of ventriculoperitoneal shunts.
CASE DESCRIPTION
A patient with a history of global developmental delay presented with shunt failure secondary to an intrahepatic cerebrospinal fluid pseudocyst. The diagnosis had not been initially apparent owing to the absence of ventriculomegaly or a palpable abdominal mass and/or tenderness. Following diagnosis on abdominal imaging, the pseudocyst was aspirated, and the ventriculoperitoneal shunt was successfully revised.
CONCLUSIONS
A series of 22 cases of previously reported intrahepatic pseudocysts and abscesses is presented, and the putative mechanisms that have been put forward to explain the development of these collections are discussed. Review of the literature demonstrates that several techniques have been successfully employed in the management of this complication.
Topics: Cerebrospinal Fluid; Cysts; Female; Humans; Liver Diseases; Ventriculoperitoneal Shunt; Young Adult
PubMed: 30721775
DOI: 10.1016/j.wneu.2019.01.150 -
Gastrointestinal Endoscopy Clinics of... Oct 2018Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The...
Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.
Topics: Drainage; Endoscopy, Digestive System; Gastrostomy; Humans; Necrosis; Pancreas; Pancreatic Cyst; Stents
PubMed: 30241639
DOI: 10.1016/j.giec.2018.06.002 -
Surgical Endoscopy May 2019The use of fully covered metal stents (FCSEMS) and specifically designed lumen apposing metal stents for transmural drainage of pancreatic fluid collections has become... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The use of fully covered metal stents (FCSEMS) and specifically designed lumen apposing metal stents for transmural drainage of pancreatic fluid collections has become widespread. A systematic review published in 2015 did not support the routine use of metal stents for drainage of pancreatic fluid collections. However, recent studies have shown conflicting data; therefore a systematic review and meta-analysis was performed.
METHOD
We conducted a database search for original comparative studies between plastic and metal stents. The random effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Outcomes analysed were clinical success, adverse events and requirement of further intervention.
RESULTS
The search identified 936 studies, 7 studies with 681 (340 metal, 341 plastic) patients met inclusion criteria and were included in the meta-analysis. Clinical success was achieved in 93.8% versus 86.2% in the metal and plastic groups, respectively, RR 1.08 [95% CI 1.02-1.14]; p = 0.009. Adverse events were reduced for metal stents when compared with plastic (10.2% vs. 25.0%), RR 0.42 [95% CI 0.22-0.81]; p = 0.010. Metal stent usage reduced bleeding (2.8% vs. 7.9%), RR 0.37; [95% CI 0.18-0.75]; p = 0.006. Further intervention was required in 12.4% of patients in the metal stent group versus 26.7% for plastic stents, RR 0.54; [95% CI 0.22-1.29]; p = 0.165.
CONCLUSIONS
The use of metal stents for drainage of pancreatic fluid collections is associated with improved clinical success, fewer adverse events and reduced bleeding compared to plastic stents.
Topics: Aged; Drainage; Female; Hemorrhage; Humans; Male; Middle Aged; Odds Ratio; Pancreas; Pancreatic Juice; Plastics; Self Expandable Metallic Stents; Stents; Treatment Outcome
PubMed: 30191310
DOI: 10.1007/s00464-018-6416-5 -
Pancreas Sep 2018To investigate the prevalence and natural history of pancreatic pseudocysts (PCs) and parenchymal necrosis in autoimmune pancreatitis (AIP).
OBJECTIVE
To investigate the prevalence and natural history of pancreatic pseudocysts (PCs) and parenchymal necrosis in autoimmune pancreatitis (AIP).
METHOD
A search using PubMed, Embase, Scopus, and Cochrane was performed. Search terms were AIP, PC, acute fluid collection, and pancreatic necrosis.
RESULTS
Fifteen studies with 17 patients were included. In 8 of 17 patients, PC was noted concurrently with the AIP diagnosis, whereas in the other half, PC appeared months or years after. In 10 of 17 cases, PC appeared as solitary. The location was variable. Pseudocysts were small (<3 cm) in 4 cases and large (>3 cm) in 13 cases. A normal pancreatic duct was observed in 6 of 17 cases, whereas 9 of 17 had pancreatic duct stenosis. Steroids were given to 4 of 4 small and 10 of 13 large PC. All small PC resolved with steroids, whereas only 4 of 10 large PC treated had some response. Most (9/13) of large PC underwent endoscopic or surgical procedures. None of the 17 cases developed necrosis.
CONCLUSIONS
Pseudocysts in AIP are rare. Pancreatic pseudocyst can present in variable number, size, and location. Small PC resolved with steroids. Large PC had poor response to steroids requiring invasive interventions. Necrosis in AIP has not been reported.
Topics: Autoimmune Diseases; Humans; Necrosis; Pancreas; Pancreatic Pseudocyst; Pancreatitis; Risk Assessment; Risk Factors; Steroids
PubMed: 30028447
DOI: 10.1097/MPA.0000000000001121 -
HPB : the Official Journal of the... Dec 2018Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of...
BACKGROUND
Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.
METHODS
Systematic literature review until May 2018.
RESULTS
Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.
CONCLUSION
Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.
Topics: Abdominal Injuries; Cholangiopancreatography, Endoscopic Retrograde; Clinical Decision-Making; Drainage; Female; Humans; Injury Severity Score; Male; Middle Aged; Pancreas; Pancreatectomy; Patient Selection; Risk Factors; Stents; Time Factors; Treatment Outcome
PubMed: 30005994
DOI: 10.1016/j.hpb.2018.05.009