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The Surgeon : Journal of the Royal... Aug 2014Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.
METHODS
A systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.
RESULTS
For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD.
CONCLUSIONS
The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.
Topics: Duodenal Diseases; Humans; Laparotomy; Minimally Invasive Surgical Procedures; Pancreatic Diseases; Pancreaticoduodenectomy; Robotics; Treatment Outcome
PubMed: 24525404
DOI: 10.1016/j.surge.2014.01.006 -
Journal of Pediatric Surgery Aug 2013To compare LILT and STEP, the two principal procedures to lengthen the native bowel in children with a short bowel syndrome (SBS), by discussing the indications and... (Comparative Study)
Comparative Study Review
PURPOSE
To compare LILT and STEP, the two principal procedures to lengthen the native bowel in children with a short bowel syndrome (SBS), by discussing the indications and presenting the outcome from published data.
METHODS
A review of literature was performed. N=39 publications were reviewed.
RESULTS
For LILT and STEP, failure to achieve intestinal autonomy by conservative therapy represents the main indication, and end-stage liver disease the main contraindication. A sufficiently dilated intestinal segment is a common anatomical precondition for both procedures. STEP can be performed on shorter intestinal segments and on intricate segments such as the duodenum, which is technically not feasible for LILT. Both procedures have a similar extent of intestinal lengthening (approximately 70%) and result in improvement of enteral nutrition and reversal of complications of parenteral nutrition. STEP seems to have a lower mortality and overall progression to transplantation.
CONCLUSIONS
STEP and LILT are both accepted procedures for non-transplant surgical management of SBS in children. The outcome after STEP seems to be more favourable, but larger series are needed to further assess accurate selection of eligible patients and to estimate effectiveness of procedures. A considerably higher number of cases for evaluation might be accomplished through the widespread use of a centralised registry.
Topics: Adolescent; Bacterial Translocation; Child; Child, Preschool; Comorbidity; Contraindications; Digestive System Surgical Procedures; Enteral Nutrition; Female; Follow-Up Studies; Humans; Infant; Infant, Newborn; Intestine, Small; Intestines; Liver Failure; Male; Malnutrition; Parenteral Nutrition; Postoperative Complications; Recovery of Function; Sepsis; Short Bowel Syndrome; Treatment Outcome
PubMed: 23932625
DOI: 10.1016/j.jpedsurg.2013.05.018 -
Surgical Endoscopy Sep 2013Since delta-shaped gastroduodenostomy was introduced, many surgeons have utilized laparoscopic distal gastrectomy (LDG) with totally intracorporeal Billroth I (ICBI) for... (Comparative Study)
Comparative Study Meta-Analysis Review
Comparing the short-term outcomes of totally intracorporeal gastroduodenostomy with extracorporeal gastroduodenostomy after laparoscopic distal gastrectomy for gastric cancer: a single surgeon's experience and a rapid systematic review with meta-analysis.
BACKGROUND
Since delta-shaped gastroduodenostomy was introduced, many surgeons have utilized laparoscopic distal gastrectomy (LDG) with totally intracorporeal Billroth I (ICBI) for gastric cancer, because it is expected to have several advantages over laparoscopic-assisted distal gastrectomy with extracorporeal Billroth I (ECBI). In this study, we compared these two reconstruction options to evaluate their outcomes.
METHODS
The data of 166 gastric cancer patients who underwent LDG performed by a single surgeon between April 2009 and February 2012 were analyzed retrospectively. The subjects were divided into ECBI (n = 106) and ICBI (n = 60) groups, and then the clinical characteristics, surgical outcomes, symptoms, and change in BMI at 3 months after surgery were compared. Furthermore, a rapid systematic review and meta-analysis were conducted.
RESULTS
The operative time was significantly shorter in the ICBI group (197.4 ± 45.5 vs. 157.1 ± 43.9 min), but blood loss was similar between the groups. Regarding surgical outcomes, there were no significant differences in the length of hospital stay, soft diet initiation, visual analogue scale, frequency of analgesics injection, and postoperative white blood cell counts and C-reactive protein levels between the groups. The surgical complication rates were 5.7 and 13.3% in the ECBI and ICBI groups, respectively, and one case of anastomosis leakage was observed in each group. At 3 months after surgery, reflux symptoms were more frequent in the ICBI group, but other gastrointestinal symptoms and the change of BMI were similar between the groups. The meta-analysis revealed no significant differences in the operative time, time to first flatus, length of hospital stay, frequency of analgesic usages, and rates of anastomosis complications between the groups.
CONCLUSIONS
We could not demonstrate the clinical superiority of ICBI over ECBI based on our data and a rapid systematic review and meta-analysis. The anastomosis method may be selected according to patient conditions and the surgeon's preference.
Topics: Blood Loss, Surgical; C-Reactive Protein; Diet; Duodenum; Female; Gastroenterostomy; Humans; Length of Stay; Male; Middle Aged; Operative Time; Pain Management; Retrospective Studies; Stomach Neoplasms; Treatment Outcome
PubMed: 23494509
DOI: 10.1007/s00464-013-2869-8 -
Journal of Research in Medical Sciences... Mar 2012Helicobacter pylori (H. pylori) infection is known as a major etiologic factor for a variety of gastroduodenal diseases. In Iran, with a high rate of H. pylori infection...
BACKGROUND
Helicobacter pylori (H. pylori) infection is known as a major etiologic factor for a variety of gastroduodenal diseases. In Iran, with a high rate of H. pylori infection close to 90%, numerous studies have revealed many aspects of interaction between the bacterium, mucosal surface and induction of disease outcome. The organism is genetically diverse and several virulence factors are attributed to the more virulent strains. The well-characterized virulence factors of H. pylori are cytotoxin associated gene A and vacuolating cytotoxin gene A. The distribution pattern of H. pylori genotypes and its association with disease status varies geographically. The present review focused on the virulence factors and genotyping of H. pylori in relation to gastroduodenal disorders in different regions of Iran.
METHODS
In total, 398 studies were reported on different aspects related to H. pylori in our electronic search from 1995-2011. H. pylori infection and its virulence factors in association with disease status were investigated in 159 reports. Looking specifically at the gastrointestinal tract disorders, the most relevant reports including 37 papers were selected.
RESULTS
We found no correlation of cagA genotype and disease status in the majority of studies, whereas vacA was demonstrated as a useful marker in predicting the disease outcome. The results of reports on other virulence factors of H. pylori such as blood group antigen-binding adhesion gene A, the induced by contact with epithelium gene A, the outer inflammatory protein A, the duodenal ulcer promoting gene A, and Helicobacter outer membrane gene and their relation with disease status were contradictory.
CONCLUSIONS
Although different markers of H. pylori were emphasized as useful when predicting disease outcomes in some studies, the inconsistent researches and the scarcity of data made any conclusion or even comparison impossible. Considering the gap of information observed during our search relating to genotyping and other aspects of H. pylori infection, further investigations are suggested.
PubMed: 23267382
DOI: No ID Found -
Journal of Vascular Surgery Mar 2012A systematic review of the literature on symptomatic duodenal perforation caused by inferior vena cava (IVC) filters. (Review)
Review
OBJECTIVE
A systematic review of the literature on symptomatic duodenal perforation caused by inferior vena cava (IVC) filters.
METHODS
Three databases, PubMed MEDLINE, Web of Sciences, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), reference lists of review articles and conference proceedings were searched. All articles containing data on clinical presentation, diagnostic strategy, and available treatment of symptomatic duodenal perforation caused by an IVC filter were included regardless of design, language, size, or length of follow-up.
RESULTS
Seventy-two articles were selected for full-text screening, being 21 case reports were selected. The median age was 46 years old (range, 21-83 years old). Abdominal pain was reported in 11 patients and gastrointestinal bleed in 5 patients. The indications for IVC filter placement in this cohort of patients were contraindication of anticoagulation and recurrent pulmonary embolism (PE) despite therapeutic levels in 8 and 5 patients, respectively. Three different imaging modalities were obtained in 9 patients (43%) before confirming the diagnosis. All but 1 patient underwent open approach through laparotomy with or without removal of the filter. No PEs or deaths were reported and only 1 patient had a severe clinical complication of IVC and bilateral iliac vein thrombosis with massive lower extremities edema.
CONCLUSIONS
Duodenal perforation caused by IVC filters is a rare complication that frequently requires extensive workup. Excellent outcomes with low complication rate have been reported in cases where an open procedure was performed with either extraction of the filter or removal of the offending struts.
Topics: Abdominal Pain; Adult; Aged; Aged, 80 and over; Device Removal; Duodenum; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Male; Middle Aged; Prosthesis Design; Treatment Outcome; Vena Cava Filters; Young Adult
PubMed: 22209606
DOI: 10.1016/j.jvs.2011.09.082 -
PharmacoEconomics Jun 2011Intravenous esomeprazole (Nexium®) is approved in Europe for the prevention of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers.... (Review)
Review
Intravenous esomeprazole (Nexium®) is approved in Europe for the prevention of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers. In a pivotal clinical trial, patients with peptic ulcer bleeding and high-risk stigmata who received intravenous esomeprazole for 72 hours following endoscopic haemostatic therapy were significantly less likely than those receiving intravenous placebo to experience recurrent peptic ulcer bleeding at days 3, 7 and 30. In addition, the need for repeat endoscopic haemostatic therapy, the total amount of blood transfused and the number of additional hospital days required because of rebleeding were significantly lower in intravenous esomeprazole recipients than in intravenous placebo recipients. All patients received oral esomeprazole for 27 days following intravenous study drug administration. Intravenous esomeprazole was generally well tolerated in the pivotal trial, with infusion-site reactions being among the most commonly reported adverse events. Two pharmacoeconomic analyses conducted from a healthcare payer perspective used decision-tree models with 30-day time horizons to examine the cost effectiveness and cost utility of intravenous esomeprazole in patients with bleeding peptic ulcers who had undergone endoscopic haemostatic therapy. With regard to the incremental cost per bleed averted, intravenous esomeprazole was predicted to be dominant in Spain and cost effective in Sweden and the US compared with no intravenous esomeprazole. Efficacy results and resource utilization data from the pivotal clinical trial were inputted into this model, and the results of the analysis were generally robust to plausible variations in key variables. In the cost-utility analysis, which was conducted in the UK and is available as an abstract and poster, esomeprazole was considered to be the most cost-effective treatment alternative, compared with omeprazole or pantoprazole. For this analysis, clinical outcomes data were obtained from a systematic review and mixed treatment comparison (given the absence of head-to-head trial data), and utility values were proxied from the literature. In conclusion, intravenous esomeprazole prevents peptic ulcer rebleeding in patients who have undergone endoscopic haemostatic therapy. Pharmacoeconomic analyses support the use of intravenous esomeprazole following endoscopic haemostatic therapy in patients with peptic ulcer bleeding and high-risk stigmata.
Topics: Anti-Ulcer Agents; Esomeprazole; Humans; Injections, Intravenous; Omeprazole; Peptic Ulcer Hemorrhage; Secondary Prevention
PubMed: 21568358
DOI: 10.2165/11207430-000000000-00000 -
The Cochrane Database of Systematic... May 2011Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of the procedures is more favourable in terms of survival, mortality, complications and quality of life.
OBJECTIVES
The objective of this systematic review is to compare the effectiveness of each operation.
SEARCH STRATEGY
We conducted searches on 28 March 2006 and 11 January 2011 to identify all randomised controlled trials (RCTs), applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), CDSR and DARE from The Cochrane Library (2010, Issue 4), MEDLINE (1966 to January 2011), and EMBASE (1980 to January 2011). Abstracts from Digestive Disease Week and U nited European Gastroenterology Week (1995 to 2010). No additional studies were indentified upon updating the systematic review in 2011.
SELECTION CRITERIA
We considered RCTs comparing the CW with PPW to be eligible if they included patients with periampullary or pancreatic carcinoma.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using mean differences (MD) and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality and risk of bias of the included studies according to Cochrane standards.
MAIN RESULTS
We included six randomised controlled trials with a total of 465 patients. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. In-hospital mortality (OR 0.49; 95% confidence interval (CI) 0.17 to 1.40; P = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 0.29) and morbidity showed no significant differences. However, we noted that operating time (MD -68.26 minutes; 95% CI -105.70 to -30.83; P = 0.0004) and intra-operative blood loss (MD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the PPW group. All significant results have low quality of evidence based on GRADE criteria.
AUTHORS' CONCLUSIONS
There is no evidence of relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
Topics: Ampulla of Vater; Common Bile Duct Neoplasms; Gastric Emptying; Humans; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 21563148
DOI: 10.1002/14651858.CD006053.pub4 -
Alimentary Pharmacology & Therapeutics Jul 2011There may be a positive association between coeliac disease and serum hypertransaminasaemia but evidence is conflicting. (Meta-Analysis)
Meta-Analysis
BACKGROUND
There may be a positive association between coeliac disease and serum hypertransaminasaemia but evidence is conflicting.
AIMS
To conduct a systematic review and meta-analysis to determine the prevalence of coeliac disease in adults presenting with cryptogenic serum hypertransaminasaemia and the prevalence of hypertransaminasaemia in patients with newly diagnosed coeliac disease.
METHODS
MEDLINE and EMBASE were searched up to August 2010. Case series and case-control studies recruiting adults with either cryptogenic hypertransaminasaemia that applied serological tests for coeliac disease and/or distal duodenal biopsy to participants or newly diagnosed biopsy-proven coeliac disease that assessed serum transaminases were eligible. The pooled prevalence of coeliac disease in individuals presenting with abnormal serum transaminases and the pooled prevalence of hypertransaminasaemia in newly diagnosed coeliac disease were calculated with 95% confidence intervals (CI).
RESULTS
Eleven eligible studies were identified. Pooled prevalences of positive coeliac serology and biopsy-proven coeliac disease in cryptogenic hypertransaminasaemia were 6% (95% CI 3% to 10%) and 4% (95% CI 1% to 7%) respectively. Pooled prevalence of abnormal serum transaminases in newly diagnosed coeliac disease was 27% (95% CI 13% to 44%). Exclusion of gluten led to normalisation of serum transaminase levels in 63% to 90% of patients within 1 year.
CONCLUSIONS
Undetected coeliac disease is a potential cause for cryptogenic hypertransaminasaemia in 3% to 4% of cases. More than 20% of individuals with newly diagnosed coeliac disease may have abnormal serum transaminases and these normalise on a gluten-free diet in the majority of cases.
Topics: Adult; Aged; Aged, 80 and over; Celiac Disease; Confidence Intervals; Female; Humans; Liver Diseases; Male; Middle Aged; Prevalence; Transaminases
PubMed: 21545472
DOI: 10.1111/j.1365-2036.2011.04685.x -
The Cochrane Database of Systematic... Feb 2011Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple... (Review)
Review
WITHDRAWN: Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma.
BACKGROUND
Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple operation or a pylorus-preserving pancreaticoduodenectomy. It is unclear which of the procedures is more favourable in terms of survival, mortality, complications and quality of life.
OBJECTIVES
Several publications have highlighted advantages and disadvantages of the two techniques and the current basis of evidence remains unclear. The objective of this systematic review is to compare the effectiveness of each operation.
SEARCH STRATEGY
We conducted a search on 28/03/2006 to identify all RCTs, applying no language restriction.We searched the following electronic databases: CENTRAL, CDSR and DARE from The Cochrane Library (2006, issue 2), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). We handsearched abstracts from 1995 to 2006 from the American Digestive Disease Week (DDW), published in Gastroenterology, and the United European Gastroenterology Week (UEGW), published in Gut.
SELECTION CRITERIA
We considered randomised controlled trials comparing the classic Whipple operation with pylorus-preserving pancreaticoduodenectomy to be eligible if they included patients with periampullary or pancreatic carcinoma.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using weighted mean differences (WMD), and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality of included studies according to quality standards and by using a questionnaire.
MAIN RESULTS
We retrieved 1235 abstracts and checked these for eligibility, including seven randomised controlled trials. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Our comparisons of in-hospital mortality (OR 0.49; 95% confidence interval (CI) 0.17 to 1.40; P = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 0.29) and morbidity showed no significant differences. However, we noted that operating time (WMD -68.26 minutes; 95% CI -105.70 to -30.83; P = 0.0004) and intra-operative blood loss (WMD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the pylorus-preserving pancreaticoduodenectomy group.
AUTHORS' CONCLUSIONS
There is no evidence of relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
Topics: Ampulla of Vater; Common Bile Duct Neoplasms; Gastric Emptying; Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 21328281
DOI: 10.1002/14651858.CD006053.pub3 -
Pediatric Critical Care Medicine : a... Jan 2010To identify and evaluate the quality of evidence supporting prophylactic use of treatments for stress ulcers and upper gastrointestinal bleeding. Stress ulcers, erosions... (Review)
Review
OBJECTIVE
To identify and evaluate the quality of evidence supporting prophylactic use of treatments for stress ulcers and upper gastrointestinal bleeding. Stress ulcers, erosions of the stomach and duodenum, and upper gastrointestinal bleeding are well-known complications of critical illness in children admitted to the pediatric intensive care unit.
DATA SOURCES
Studies were identified from the Cochrane Central Register of Controlled Trials, PUBMED; LILACS; Scirus. We also scanned bibliographies of relevant studies.
STUDY SELECTION
This systematic review of randomized controlled trials assessed the effects of drugs for stress-related ulcers, gastritis, and upper gastrointestinal bleeding in critically ill children admitted to the pediatric intensive care unit.
DATA EXTRACTION AND SYNTHESIS
Two reviewers independently extracted the relevant data. Most randomized controlled trials were judged as having unclear risk of bias. When pooling two randomized controlled trials, treatment was significantly more effective in preventing upper gastrointestinal bleeding (macroscopic or important bleeding) compared with no treatment (two studies = 300 participants; relative risk, 0.41; 95% confidence interval, 0.19-0.91; I = 12%). Meta-analysis of two studies found no significant difference in death rates among groups (two randomized controlled trials = 132 participants; relative risk, 1.39; 95% confidence interval, 0.70-2.79; I = 4%). The rate of pneumonia was not significantly different when comparing treatment and no treatment in one study. When comparing ranitidine with no treatment, significant differences were found in the proportion of mechanically ventilated children with normal gastric mucosal endoscopic findings by histologic specimens (one randomized controlled trial = 48 participants; relative risk, 3.53; 95% confidence interval, 1.34-9.29). No significant differences were found when comparing different drugs (omeprazole, ranitidine, sucralfate, famotidine, amalgate), doses, or regimens for main outcomes (deaths, endoscopic findings of erosion or ulcers, upper gastrointestinal bleeding, or pneumonia).
CONCLUSIONS
Although pooled data of two studies suggested that critically ill pediatric patients may benefit from receiving prophylactic treatment to prevent upper gastrointestinal bleeding, we found that high-quality evidence to guide clinical practice is still limited.
Topics: Critical Illness; Evidence-Based Medicine; Gastritis; Gastrointestinal Hemorrhage; Humans; Intensive Care Units, Pediatric; Randomized Controlled Trials as Topic; Stomach Ulcer; Stress, Psychological
PubMed: 19770788
DOI: 10.1097/PCC.0b013e3181b80e70