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BMC Gastroenterology Jul 2018Laparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and periampullary malignancy. The purpose of this meta-analysis was to compare LPD with OPD for these malignancies regarding short-term surgical and long-term survival outcomes.
METHODS
A literature search was conducted before March 2018 to identify comparative studies in regard to outcomes of both LPD and OPD for the treatment of pancreatic-head and periampullary malignancies. Morbidity, postoperative pancreatic fistula (POPF), mortality, operative time, estimated blood loss, hospitalization, retrieved lymph nodes, and survival outcomes were compared.
RESULTS
Among eleven identified studies, 1196 underwent LPD, and 8247 were operated through OPD. The pooled data showed that LPD was associated with less morbidity (OR = 0.57, 95%CI: 0.41~ 0.78, P < 0.01), less blood loss (WMD = - 372.96 ml, 95% CI, - 507.83~ - 238.09 ml, P < 0.01), shorter hospital stays (WMD = - 197.49 ml, 95% CI, - 304.62~ - 90.37 ml, P < 0.01), and comparable POPF (OR = 0.85, 95%CI: 0.59~ 1.24, P = 0.40), and overall survival (HR = 1.03, 95%CI: 0.93~ 1.14, P = 0.54) compared to OPD. Operative time was longer in LPD (WMD = 87.68 min; 95%CI: 27.05~ 148.32, P < 0.01), whereas R0 rate tended to be higher in LPD (OR = 1.17; 95%CI: 1.00~ 1.37, P = 0.05) and there tended to be more retrieved lymph nodes in LPD (WMD = 1.15, 95%CI: -0.16~ 2.47, P = 0.08), but these differences failed to reach statistical significance.
CONCLUSIONS
LPD can be performed as safe and effective as OPD for pancreatic-head and periampullary malignancy with respect to both surgical and oncological outcomes. LPD is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OPD in selected individuals in the future.
Topics: Adenocarcinoma; Ampulla of Vater; Blood Loss, Surgical; Common Bile Duct Neoplasms; Humans; Laparoscopy; Length of Stay; Lymphatic Metastasis; Operative Time; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Survival Analysis
PubMed: 29969999
DOI: 10.1186/s12876-018-0830-y -
BMC Gastroenterology Nov 2017Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.
METHODS
Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.
RESULTS
One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.
CONCLUSION
Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.
Topics: Ampulla of Vater; Blood Loss, Surgical; Blood Transfusion; Common Bile Duct Diseases; Humans; Length of Stay; Minimally Invasive Surgical Procedures; Operative Time; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 29169337
DOI: 10.1186/s12876-017-0691-9 -
The Cochrane Database of Systematic... Sep 2017Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference.
OBJECTIVES
To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions.
SELECTION CRITERIA
We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability.
MAIN RESULTS
We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data.
AUTHORS' CONCLUSIONS
There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.
Topics: Gastrostomy; Humans; Length of Stay; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 28898386
DOI: 10.1002/14651858.CD012257.pub2 -
World Journal of Emergency Surgery :... 2017Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric... (Review)
Review
BACKGROUND
Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided.
CASE PRESENTATION
A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition.
CONCLUSIONS
No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Debridement; Drainage; Humans; Male; Middle Aged; Multiple Organ Failure; Pancreatitis, Acute Necrotizing; Tomography, X-Ray Computed; Ultrasonography; Video-Assisted Surgery
PubMed: 28331537
DOI: 10.1186/s13017-017-0126-5 -
World Journal of Gastrointestinal... Jan 2017To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).
AIM
To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).
METHODS
A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.
RESULTS
A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.
CONCLUSION
There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.
PubMed: 28138366
DOI: 10.4240/wjgs.v9.i1.25 -
The Cochrane Database of Systematic... Feb 2016Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW)... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life.
OBJECTIVES
The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.
SEARCH METHODS
We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015.
SELECTION CRITERIA
RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration.
MAIN RESULTS
We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.
AUTHORS' CONCLUSIONS
Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.
Topics: Ampulla of Vater; Blood Loss, Surgical; Common Bile Duct Neoplasms; Female; Gastric Emptying; Humans; Male; Operative Time; Organ Sparing Treatments; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 26905229
DOI: 10.1002/14651858.CD006053.pub6 -
The Cochrane Database of Systematic... Feb 2016Surgical excision by removal of the head of the pancreas to decompress the obstructed ducts is one of the treatment options for people with symptomatic chronic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical excision by removal of the head of the pancreas to decompress the obstructed ducts is one of the treatment options for people with symptomatic chronic pancreatitis. Surgical excision of the head of the pancreas can be performed by excision of the duodenum along with the head of the pancreas (pancreaticoduodenectomy (PD)) or without excision of the duodenum (duodenum-preserving pancreatic head resection (DPPHR)). There is currently no consensus on the method of pancreatic head resection in people with chronic pancreatitis.
OBJECTIVES
To assess the benefits and harms of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in people with chronic pancreatitis for whom pancreatic resection is considered the main treatment option.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to June 2015 to identify randomised trials. We also searched the references of included trials to identify further trials.
SELECTION CRITERIA
We considered only randomised controlled trials (RCT) performed in people with chronic pancreatitis undergoing pancreatic head resection, irrespective of language, blinding, or publication status, for inclusion in the review.
DATA COLLECTION AND ANALYSIS
Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR), mean difference (MD), rate ratio (RaR), or hazard ratio (HR) with 95% confidence intervals (CI) based on an available-case analysis.
MAIN RESULTS
Five trials including 292 participants met the inclusion criteria for the review. After exclusion of 23 participants mainly due to pancreatic cancer or because participants did not receive the planned treatment, a total of 269 participants (with symptomatic chronic pancreatitis involving the head of pancreas and requiring surgery) were randomly assigned to receive DPPHR (135 participants) or PD (134 participants). The trials did not report the American Society of Anesthesiologists (ASA) status of the participants. All the trials were single-centre trials and included people with and without obstructive jaundice and people with and without duodenal stenosis but did not report data separately for those with and without jaundice or those with and without duodenal stenosis. The surgical procedures compared in the five trials included DPPHR (Beger or Frey procedures, or wide local excision of the head of the pancreas) and PD (pylorus-preserving pancreaticoduodenectomy or Whipple procedure). The participants were followed up for various periods of time ranging from one to 15 years. The trials were at unclear or high risk of bias. The overall quality of evidence was low or very low.The differences in short-term mortality (up to 90 days after surgery) (RR 2.89, 95% CI 0.31 to 26.87; 369 participants; 5 studies; DPPHR: 2/135 (1.5%) versus PD: 0/134 (0%); very low quality evidence) or long-term mortality (maximal follow-up) (HR 0.65, 95% CI 0.31 to 1.34; 229 participants; 4 studies; very low quality evidence), medium-term (three months to five years) (only a narrative summary was possible; 229 participants; 4 studies; very low quality evidence), or long-term quality of life (more than five years) (MD 8.45, 95% CI -0.27 to 17.18; 101 participants; 2 studies; low quality evidence), proportion of people with adverse events (RR 0.55, 95% CI 0.22 to 1.35; 226 participants; 4 studies; DPPHR: 23/113 (adjusted proportion 20%) versus PD: 41/113 (36.3%); very low quality evidence), number of people with adverse events (RaR 0.95, 95% CI 0.43 to 2.12; 43 participants; 1 study; DPPHR: 12/22 (54.3 events per 100 participants) versus PD: 12/21 (57.1 events per 100 participants); very low quality evidence), proportion of people employed (maximal follow-up) (RR 1.54, 95% CI 1.00 to 2.37; 189 participants; 4 studies; DPPHR: 65/98 (adjusted proportion 69.4%) versus PD: 41/91 (45.1%); low quality evidence), incidence proportion of diabetes mellitus (maximum follow-up) (RR 0.78, 95% CI 0.50 to 1.22; 269 participants; 5 studies; DPPHR: 25/135 (adjusted proportion 18.6%) versus PD: 32/134 (23.9%); very low quality evidence), and prevalence proportion of pancreatic exocrine insufficiency (maximum follow-up) (RR 0.83, 95% CI 0.68 to 1.02; 189 participants; 4 studies; DPPHR: 62/98 (adjusted proportion 62.0%) versus PD: 68/91 (74.7%); very low quality evidence) were imprecise. The length of hospital stay appeared to be lower with DPPHR compared to PD and ranged between a reduction of one day and five days in the trials (208 participants; 4 studies; low quality evidence). None of the trials reported short-term quality of life (four weeks to three months), clinically significant pancreatic fistulas, serious adverse events, time to return to normal activity, time to return to work, and pain scores using a visual analogue scale.
AUTHORS' CONCLUSIONS
Low quality evidence suggested that DPPHR may result in shorter hospital stay than PD. Based on low or very low quality evidence, there is currently no evidence of any difference in the mortality, adverse events, or quality of life between DPPHR and PD. However, the results were imprecise and further RCTs are required on this topic. Future RCTs comparing DPPHR with PD should report the severity as well as the incidence of postoperative complications and their impact on patient recovery. In such trials, participant and observer blinding should be performed and the analysis should be performed on an intention-to-treat basis to decrease the bias. In addition to the short-term benefits and harms such as mortality, surgery-related complications, quality of life, length of hospital stay, return to normal activity, and return to work, future trials should consider linkage of trial participants to health databases, social databases, and mortality registers to obtain the long-term benefits and harms of the different treatments.
Topics: Duodenum; Humans; Length of Stay; Organ Sparing Treatments; Pancreatectomy; Pancreaticoduodenectomy; Pancreatitis, Chronic; Randomized Controlled Trials as Topic
PubMed: 26837472
DOI: 10.1002/14651858.CD011521.pub2 -
World Journal of Gastroenterology Jun 2015To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer. (Review)
Review
AIM
To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.
METHODS
A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.
RESULTS
In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.
CONCLUSION
Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.
Topics: Anastomotic Leak; Drainage; Duodenal Diseases; Duodenum; Gastrectomy; Humans; Intestinal Fistula; Length of Stay; Reoperation; Stomach Neoplasms; Time Factors; Treatment Outcome; Wound Healing
PubMed: 26140005
DOI: 10.3748/wjg.v21.i24.7571 -
The Cochrane Database of Systematic... Nov 2014Background Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours consists of a... (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 consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these 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 CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.Search methods We conducted searches on 28 March 2006, 11 January 2011 and 9 January 2014 to identify all randomised controlled trials (RCTs),while applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects(DARE) from The Cochrane Library (2013, Issue 4); MEDLINE (1946 to January 2014); and EMBASE (1980 to January 2014). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010). We identified no additional studies upon updating the systematic review in 2014.Selection criteria We considered RCTs comparing CW versus PPW to be eligible if they included study participants with periampullary or pancreatic carcinoma. Data collection and analysis Two review authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs) and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included studies according to the standards of The Cochrane Collaboration.Main results We included six RCTs with a total of 465 participants. 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 value 0.18), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P value 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 value 0.0004) and intraoperative blood loss (MD -0.76 mL, 95%CI -0.96 to -0.56; P value < 0.00001) were significantly reduced in the PPW group. All significant results are associated with low quality of evidence as determined on the basis of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.Authors' conclusions No evidence suggests 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; Blood Loss, Surgical; Common Bile Duct Neoplasms; Gastric Emptying; Humans; Operative Time; Organ Sparing Treatments; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 25387229
DOI: 10.1002/14651858.CD006053.pub5 -
European Journal of Vascular and... Oct 2009Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management. (Review)
Review
AIM
Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management.
METHODS
An electronic search of the pertinent English and French literature was undertaken. All studies reporting on aneurysms of visceral veins were considered. Cases describing patients with arterial-venous fistulae and extrahepatic or intra-hepatic portosystemic venous shunts were excluded.
RESULTS
Ninety-three reports were identified, including 176 patients with 198 visceral venous aneurysms. Patients' age ranges from 0 to 87 years, and there is no apparent male/female preponderance. The commonest location of visceral venous aneurysms is the portal venous system (87 of 93 reports, 170 of 176 patients, 191 of 198 aneurysms). Aneurysms of the renal veins and inferior mesenteric vein are also described. Portal system venous aneurysms were present with abdominal pain in 44.7% of the patients, gastrointestinal bleeding in 7.3%, and are asymptomatic in 38.2%. Portal hypertension is reported in 30.8% and liver cirrhosis in 28.3%. Thrombosis occurred in 13.6% and rupture in 2.2% of the patients. Adjacent organ compression is reported in 2.2% (organs compressed: common bile duct, duodenum, inferior vena cava). The management ranged from watchful waiting to intervention. In 94% of the cases, aneurysm diameter remained stable and no complications occurred during follow-up. In most of the cases, indications for operation were symptoms and complications. Six cases of renal vein aneurysm are reported; three of them were asymptomatic. Three of these patients were treated surgically.
CONCLUSION
The most frequent location of visceral venous aneurysms is the portal venous system. They are often associated with cirrhosis and portal hypertension. They may be asymptomatic or present with abdominal pain and other symptoms. Watchful waiting is an appropriate treatment, except when complications occur. Most common complications are aneurysm thrombosis and rupture. Other visceral venous aneurysms are extremely rare.
Topics: Abdominal Pain; Adolescent; Adult; Aged; Aged, 80 and over; Aneurysm; Aneurysm, Ruptured; Child; Child, Preschool; Disease Progression; Female; Humans; Infant; Infant, Newborn; Male; Mesenteric Veins; Middle Aged; Portal Vein; Renal Veins; Severity of Illness Index; Thrombosis; Treatment Outcome; Vascular Surgical Procedures; Viscera; Young Adult
PubMed: 19560947
DOI: 10.1016/j.ejvs.2009.05.016