Impact of the Timing of Endoscopic Retrograde Cholangiopancreatography for the Treatment of Acute Cholangitis: A Meta-analysis and Systematic Review.

BACKGROUND: The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis (AC) has not been unequivocally established. AIMS: To perform a meta-analysis of the outcomes associated with particular timings of ERCP for AC. METHODS: A systematic literature search was conducted for studies of ERCP for AC, and then a meta-analysis of the in-hospital mortality (IHM), 30-day mortality, and length of hospital stay (LHS) was performed. RESULTS: Seven non-randomized studies of 88,562 patients were considered appropriate for inclusion. Compared with performing ERCP more than 24 hours after admission, ERCP within 24 hours was associated with lower IHM ( P <0.0004), but no difference in 30-day mortality ( P =0.38) was found between the 2 groups. ERCP performed <48 hours after admission was associated with a lower IHM and 30-day mortality ( P <0.00001 and P =0.03) than ERCP performed >48 hours after admission. In addition, ERCP performed within 24 or 48 hours was associated with a shorter LHS ( P <0.00001 and P <0.00001, respectively). CONCLUSION: ERCP within 48 hours of admission is superior to subsequent ERCP with respect to IHM, 30-day mortality, and LHS, and ERCP performed within 24 hours is associated with lower IHM and LHS.

Safety of early same-admission laparoscopic cholecystectomy for acute mild biliary pancreatitis. A retrospective study for acute pancreatitis.

INTRODUCTION: As the standard procedure for the surgical treatment for gallbladder stones, we investigated the controversy surrounding the optimal time for laparoscopic cholecystectomy (LC) for acute mild biliary pancreatitis (AMBP). AIM: To further address the optimal timing of LC, we conducted a retrospective study comparing early (< 72 h, group I) with delayed (> 72 h, group II) LC for AMBP during the same admission. MATERIAL AND METHODS: This retrospective study included medical records of all patients who were admitted with a diagnosis of acute mild biliary pancreatitis at Dongyang People's Hospital from July 2011 to June 2019. RESULTS: A total of 119 patients were divided into an early LC group (group I; 52 patients) and a control group (group II; 67 patients). Conversion to open cholecystectomy (COC) was performed in 17 patients (6 patients in group I and 11 patients in group II, p = 0.62). There were no significant differences in terms of estimated blood loss and duration of surgery (p = 0.08 and p = 0.64, respectively). The overall hospital stay in group I was significantly shorter than in group II (10.86 ±3.21 vs. 13.29 ±4.51 days, p = 0.001). Compared with postoperative bile leakage (p = 0.72) and postoperative morbidity (p = 0.97) and mortality, there were no significant differences between the groups. CONCLUSIONS: Early LC during the same admission is safe for acute mild biliary pancreatitis and has the advantage of shortening overall hospital stay. There was no significant increase in COC, bile duct injury, and complications.

Assessment of laparoscopic versus open distal pancreatectomy: a systematic review and meta-analysis.

BACKGROUND: The surgical benefits of open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) as a treatment for pancreatic disease in the body or tail were compared. MATERIAL AND METHODS: We searched PubMed, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and Web of Science from 1 August 1990 to 1 July 2019. Studies comparing total LDP and ODP were included. RESULTS: In total, we reviewed 30 studies covering 4040 subjects. The analysis displayed a similar incidence of CR-POPF and POPF between ODP and LDP groups. The findings indicate that LDP correlates with fewer total complications, lower estimated blood loss, shorter length of stay and shorter postoperative hospital stay. There was no significant difference in the operation time, R0 resection, postoperative hemorrhage, number of lymph nodes collected, reoperation, major complications, or mortality. CONCLUSIONS: Application of the International Study Group on Pancreatic Fistula (2017) criteria in this meta-analysis showed that LDP had surgical outcomes comparable with those of ODP. However, LDP has the benefits of causing a relatively lower estimated blood loss, a small number of total complications, and a shorter hospital stay. We, however, note that further high-quality and controlled trials are required to comprehensively compare these treatments.

Comparing Outcomes Following Endoscopic Ultrasound-Guided Biliary Drainage Versus Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis.

Background: The aim of this study was to explore the efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTCD) in patients with malignant biliary obstruction and failed endoscopic retrograde cholangiopancreatography. Methods: We searched PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov to identify studies reporting outcomes comparing EUS-BD and PTCD. Results: We identified 9 studies involving 469 patients. Technical success was similar for EUS-BD and PTCD (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.17-3.30; P = .71). EUS-BD was associated with higher clinical success versus PTCD (OR, 2.11; 95% CI, 1.15-3.87; P = .02) in all studies. However, there was no significant difference between groups in studies using self-expandable metal stents (OR, 0.36; 95% CI, 0.06-2.00; P = .24). The reported adverse event rate was significantly lower for EUS-BD compared with PTCD (OR, 0.33; 95% CI, 0.22-0.52; P < .00001). Conclusion: The available literature suggests that EUS-BD is associated with fewer adverse events, greater clinical success, and comparable technical success compared with PTCD. According to the shortcomings of our study, more large, high-quality, randomized controlled trials are needed to compare these techniques and confirm our findings.

Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided drainage (EUSD) and percutaneous drainage (PD) have reportedly been used for postoperative pancreatic fluid collection (PFC). However, there is limited evidence regarding safety and efficacy in a comparison of EUSD and PD for postoperative PFC. We conducted a search of the databases PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov, to August 2020. Studies comparing EUSD and PD for postoperative PFC were included. The outcomes included technical success, clinical success, adverse events, and recurrence of PFC.We included a total of 6 studies involving 247 patients in the current study. There was no significant difference between EUSD and PD in terms of technical success (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.29-3.12; p = 0.94) and clinical success (OR = 1.36; 95% CI: 0.68-2.72; p = 0.39). PFC recurrence and adverse events were similar between the two groups (OR = 1.82; 95% CI: 0.75-4.37; p = 0.18 and OR = 0.78; 95% CI: 0.31-1.92; p = 0.58, respectively).This meta-analysis confirmed that EUSD has comparable safety and efficacy to PD for postoperative PFC. Additional high-quality studies are required in the future.

Comparison Between Lumen-Apposing Metal Stents and Plastic Stents in Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collection: A Meta-analysis and Systematic Review.

OBJECTIVES: This study aimed to explore efficacy and safety between LAMSs (lumen-apposing metal stents) and DPPSs (double-pigtail plastic stents) in endoscopic ultrasound-guided drainage for pancreatic fluid collections. METHODS: Electronic databases were searched to identify relevant studies published until July 20, 2020. RESULTS: Fifteen studies were identified in this study. Endoscopic ultrasound-guided drainage with LAMS has higher clinical success (90.01% vs 82.56%) (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.79-3.33; P < 0.00001), less recurrence (OR, 0.44; 95% CI, 0.29-0.68; P = 0.0002), and fewer additional interventions (OR, 0.34; 95% CI, 0.211-0.55; P < 0.001). There was no significant difference between LAMS and DPPS in technical success (97.45% vs 97.38%) (OR, 0.92; 95% CI, 0.50-1.70; P = 0.80), adverse events (OR, 0.92; 95% CI, 0.41-2.09; P = 0.84), stent-related adverse events (OR, 0.78; 95% CI, 0.39-1.54; P = 0.47), and bleeding (OR, 1.47; 95% CI, 0.57-3.28; P = 0.42). Lumen-apposing metal stents have slightly more perforations (OR, 7.10; 95% CI, 1.22-41.30; P = 0.03) in studies of walled-off necrosis. CONCLUSIONS: Lumen-apposing metal stents have the advantage of higher clinical success, less recurrence, and fewer additional interventions. However, LAMS may increase perforation for walled-off necrosis.

Endoscopic ultrasound-guided vs ERCP-guided biliary drainage for malignant biliary obstruction: A up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being used increasingly as an alternative treatment for malignant biliary obstruction (MBO). However, few studies have compared EUS-BD and endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD). We searched the PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases until 1 November 2020 for studies comparing EUS-BD versus ERCP-BD. The primary outcomes of interest in this study were technical and clinical success. Nine studies involving 634 patients were included in this meta-analysis. Regarding technical and clinical success, there were no significant differences between EUS-BD and ERCP-BD (odds ratio [OR], 0.76; 95% CI: 0.30-1.91; OR, 1.45, 95% confidence interval [CI], 0.66-3.16, respectively). EUS-BD was associated with significantly less reintervention vs ERCP-BD (OR, 0.36, 95% CI, 0.15-0.86). Regarding adverse events, the rates were similar for EUS-BD and ERCP-BD (OR: 0.75, 95% CI, 0.45-1.24). There were no significant differences in the types of adverse events (stent occlusion, stent migration, stent dysfunction, and duration of stent patency) between the two techniques. EUS-BD was associated with lower reintervention rates compared with ERCP-BD, with comparable safety and efficacy outcomes. However, more high-quality randomized trials are required.

Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis with High Surgical Risk: An Up-to-Date Meta-Analysis and Systematic Review.

Background: To compare the safety and effectiveness of endoscopic ultrasound-guided gallbladder drainage (EUSGBD) with percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis with high surgical risk. Methods: An electronic search was performed of the major databases, namely PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until July 1, 2020. Studies comparing EUSGBD with PTGBD were included. Results: We identified 8 studies involving 801 patients, and patients were divided into two groups (EUSGBD group = 338 and PTGBD = 463). EUSGBD was associated with less reintervention (odds ratio [OR] = 0.15; 95% confidence interval [CI]: 0.07-0.32; P < .00001) and readmission (OR = 0.24; 95% CI: 0.08-0.67; P = 7). With lumen-apposing metal stents (LAMS), EUSGBD was associated with fewer adverse events (OR = 0.35; 95% CI: 0.13-0.93; P = .03), recurrent cholecystitis (OR = 0.27; 95% CI: 0.10-0.71; P = .008) and readmission (OR = 0.10; 95% CI: 0.03-0.32; P = .0001). There were no significant differences between the groups regarding clinical success (OR = 1.47; 95% CI: 0.75-2.90; P = .26). Technical success with PTGBD was higher than that with EUSGBD (OR = 0.32; 95% CI: 0.13-0.83; P = .02). Conclusions: EUSGBD was comparable with PTGBD regarding clinical success, with less reintervention and readmission, for acute cholecystitis with high surgical risk. The cholecystitis recurrence rate was lower with EUSGBD with LAMS.

Comparison of Three Methods of Gallbladder Drainage for Patients with Acute Cholecystitis Who Are at High Surgical Risk: A Network Meta-Analysis and Systematic Review.

Background: Percutaneous gallbladder drainage (PTGBD), endoscopic ultrasound-guided gallbladder drainage (EUSGBD), and endoscopic transpapillary gallbladder drainage (ETGBD) are used for the treatment of patients with acute cholecystitis who are at high surgical risk. However, it is unclear which procedure is associated with the best outcomes. Methods: We systematically searched records in PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov up to March 1, 2020. Studies that compared at least two of PTGBD, ETGBD, and EUSGBD were included. Results: A total of 13 studies were included in the present analyses. PTGBD, EUSGBD, and ETGBD were associated with similar clinical success, adverse event, recurrent cholecystitis, reintervention, and mortality rates. PTGBD was associated with a higher technical success rate than EUSGBD (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.40-1.41) or ETGBD (OR = 0.73, 95% CI = 0.35-1.53). EUSGBD was associated with the highest probability of clinical success (67.5%), and the lowest prevalences of adverse events (57.0%) and recurrent cholecystitis (60.9%). ETGBD was associated with the best reintervention outcomes (81.8%). Conclusions: Compared with PTGBD and ETGBD, EUSGBD appears to be preferable with respect to both safety and efficacy for the treatment of patients with acute cholecystitis who are at high surgical risk.

Early laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis.

There is no consensus on the optimal timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute cholecystitis (AC). We retrospectively evaluated patients who underwent LC after PTGBD between 1 February 2016 and 1 February 2020. We divided patients into three groups according to the interval time between PTGBD and LC as follows: Group I (within 1 week), (Group II, 1 week to 1 month), and Group III (> 1 month) and analyzed patients' perioperative outcomes. We enrolled 100 patients in this study (Group I, n = 22; Group II, n = 30; Group III, n = 48). We found no significant difference between the groups regarding patients' baseline characteristics and no significant difference regarding operation time and estimated blood loss (p = 0.69, p = 0.26, respectively). The incidence of conversion to open cholecystectomy was similar in the three groups (p = 0.37), and we found no significant difference regarding postoperative complications (p = 0.987). Group I had shorter total hospital stays and medical costs (p = 0.005, p < 0.001, respectively) vs Group II and Group III. Early LC within 1 week after PTGBD is safe and effective, with comparable intraoperative outcomes, postoperative complications, and conversion rates to open cholecystectomy. Furthermore, early LC could decrease postoperative length of hospital stay and medical costs.

Comparison of the Efficacy and Safety of Three Endoscopic Methods to Manage Large Common Bile Duct Stones: A Systematic Review and Network Meta-Analysis.

Background: The optimal choice of endoscopic method between endoscopic sphincterotomy (EST), endoscopic papillary large balloon dilation (EPLBD), and EST plus EPLBD (endoscopic sphincterotomy and large balloon dilation [ESLBD]) for patients with large common bile duct stones is unclear. Methods: We systematically searched MEDLINE, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from August 1, 1990 to December 1, 2019. Randomized clinical trials comparing at least two of the following methods EST, ESLBD, or EPLBD were included in this study. The primary outcomes were the overall success rate and initial success rate of common bile duct stone removal. Results: We identified 13 trials comprising 1990 patients. Regarding the overall success rate and initial success rate, EPLBD had the highest probability of being the most successful (surface under the cumulative ranking curve [SUCRA] = 82.8% and 52.9%, respectively) and the lowest probability of bleeding (53.8%). ESLBD had the highest probability (SUCRA) of having the lowest morbidity (88.8%), requiring mechanical lithotripsy (54.9%), perforation (68%), and the lowest mortality (89.3%). EST had the least probability of postendoscopic retrograde cholangiopancreatography pancreatitis and cholangitis (SUCRA: 66.4% and 62.3%, respectively). Conclusions: EPLBD was most successful, and ESLBD was safest for large common bile duct stones. Postendoscopic pancreatitis after EST was less common than that after EPLBD and ESLBD. However, more high-quality trials are required.

Comparison of 3 Minimally Invasive Methods Versus Open Distal Pancreatectomy: A Systematic Review and Network Meta-Analysis.

BACKGROUND: The efficacy and safety of open distal pancreatectomy (DP), laparoscopic DP, robot-assisted laparoscopic DP, and robotic DP have not been established. The authors aimed to comprehensively compare these 4 surgical methods using a network meta-analysis. MATERIALS AND METHODS: The authors systematically searched MEDLINE, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for studies that evaluated at least 2 of the following pancreatectomy techniques: robot-assisted DP, laparoscopic DP, open DP, and robotic DP. The surface under the cumulative ranking curve (SUCRA) was applied to show the probability that each method would be the best for each outcome. RESULTS: Altogether, 46 trials with 8377 patients were included in this network meta-analysis. Robotic DP showed the highest probability of having the least estimated blood loss (SUCRA, 90.9%), the lowest incidences of postoperative pancreatic fistula (SUCRA, 94.5%), clinically related postoperative pancreatic fistula (SUCRA, 94.6%), postoperative bleeding (SUCRA, 75.3%), reoperation (SUCRA, 96.4%), overall complications (SUCRA, 86.9%), and major complications (SUCRA, 99.3%), and the lowest mortality (SUCRA, 83.4%). Robotic DP also proved to be the best approach regarding the attainment of R0 resection (SUCRA, 75.4%) and the number of lymph nodes harvested (SUCRA, 64.1%). CONCLUSION: Robotic DP seems to offer clinical and oncological advantages compared with other DP methods for addressing diseases of the pancreatic body and tail, although it may require a longer operation time and learning curve. The present results require confirmation in future head-to-head randomized controlled trials.

Comparison of surgical outcomes between isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.

BACKGROUND: We aimed to compare the safety and effectiveness of the following procedures after pancreaticoduodenectomy: isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy. METHODS: We performed a systematic search of the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 January 2020. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated using STATA 12.0 statistical software. RESULTS: Thirteen studies involving 1942 patients were included in this study. Pooled analysis showed that reoperation rates following isolated pancreaticojejunostomy were lower reoperation than with conventional pancreaticojejunostomy (OR = 0.36, 95% CI: 0.15-0.86, p = 0.02, respectively), and that isolated pancreaticojejunostomy required longer operation time vs conventional pancreaticojejunostomy (WMD = 43.61, 95% CI: 21.64-65.58, P = 0.00). Regarding postoperative pancreatic fistula, clinically-relevant postoperative pancreatic fistula, delayed gastric emptying, clinically-relevant delayed gastric emptying, bile leakage, hemorrhage, reoperation, length of postoperative hospital stay, major complications, overall complications, and mortality, we found no significant differences for either isolated pancreaticojejunostomy versus conventional pancreaticojejunostomy or isolated gastrojejunostomy versus conventional pancreaticojejunostomy. CONCLUSIONS: This study showed that isolated pancreaticojejunostomy was associated with a lower reoperation rate, but required longer operation time vs conventional pancreaticojejunostomy. Considering the limitations, high-quality randomized controlled trials are required.

Comparison of endoscopic surgery and Lichtenstein repair for treatment of inguinal hernias: A network meta-analysis.

BACKGROUND: This study aimed to identify the best procedure for addressing inguinal hernias by comparing results after transabdominal preperitoneal (TAPP), totally extraperitoneal (TEP), and Lichtenstein repairs using a network meta-analysis. METHODS: We conducted a systematic search of MEDLINE, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to September 1, 2018 for randomized controlled trials (RCTs) comparing the TAPP, TEP, and Lichtenstein procedures. The study outcome were the hernia recurrence, chronic pain, hematoma, seroma, wound infection, operation time, hospital stay, and return-to-work days. RESULTS: Altogether, 31 RCTs were included in the meta-analysis. The results of this network meta-analysis showed there were no significantly differences among the 3 procedures in terms of hernia recurrence, chronic pain, hematoma, seroma, hospital stays. Lichtenstein had a shorter operation time than TAPP+TEP [MD (95%Crl)]: 12 (0.51-25.0) vs 18 (6.11-29.0) minutes, respectively) but was associated with more wound infections than TEP: OR 0.33 (95%Crl 0.090-0.81). Our network meta-analysis suggests that TAPP and TEP require fewer return-to-work days [MD (95%CI)]: - 3.7 (-6.3 to 1.3) vs -4.8 (-7.11 to 2.8) days. CONCLUSION: Our network meta-analysis showed that there were no differences among the TAPP, TEP, and Lichtenstein procedures in terms of safety or effectiveness for treating inguinal hernias. However, TAPP and TEP could decrease the number of return-to-work days. A further study with more focus on this topic for inguinal hernia is suggested.

Peritoneal drainage or no drainage after pancreaticoduodenectomy and/or distal pancreatectomy: a meta-analysis and systematic review.

BACKGROUND: Peritoneal drainage has been used routinely after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP). Our objective was to compare patients' outcomes after PD or DP with or without peritoneal drainage. METHODS: We performed a systematic search using the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 June 2019. We included trials comparing no peritoneal drainage versus drainage after PD and/or DP. RESULTS: Ten trials involving 2419 patients were eligible for inclusion. The meta-analysis showed a significantly lower rate of postoperative pancreatic fistula in the no-drain group (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.29-0.51; p < 0.00001). However, there was no significant difference in the analysis of the subgroups, DP and DP + PD peritoneal drainage (p = 0.10, p = 0.19; respectively). The analysis of all studies showed no significant difference between groups regarding clinically related postoperative pancreatic fistula (OR 0.71; 95% CI 0.41-1.24; p = 0.23). Mortality was higher in the drain group in the PD + DP subgroup (OR 0.41; 95% CI 0.27-0.62; p < 0.0001). No significant differences were found regarding intra-abdominal abscess, delayed gastric emptying, biliary fistula, postoperative hemorrhage, or morbidity. CONCLUSION: Our results showed comparable outcomes for PD and DP with or without drainage. However, we can draw no clear conclusions because of the study limitations. Further studies on this topic are recommended.

Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials.

BACKGROUND: We performed this study to compare the safety and feasibility of single-incision laparoscopic cholecystectomy (SILC) with conventional multiple-port laparoscopic cholecystectomy (MPLC). METHODS: We searched PubMed, Embase, Web of Science, the Cochrane Controlled Register of Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials comparing SILC versus MPLC. We evaluated the pooled outcomes for complications, pain scores, and surgery-related events. This study was performed in accordance with PRISMA guidelines. RESULTS: A total of 48 randomized controlled trials involving 2838 patients in the SILC group and 2956 patients in the MPLC group were included in this study. Our results showed that SILC was associated with a higher incidence of incisional hernia (relative risk = 2.51; 95% confidence interval = 1.23-5.12; p = 0.01) and longer operation time (mean difference = 15.27 min; 95% confidence interval = 9.67-20.87; p < 0.00001). There were no significant differences between SILC and MPLC regarding bile duct injury, bile leakage, wound infection, conversion to open surgery, retained common bile duct stones, total complication rate, and estimated blood loss. No difference was observed in postoperative pain assessed by a visual analogue scale between the two groups at four time points (6 h, 8 h, 12 h, and 24 h postprocedure). CONCLUSIONS: Based on the current evidence, SILC did not result in better outcomes compared with MPLC and both were equivalent regarding complications. Considering the additional surgical technology and longer operation time, SILC should be chosen with careful consideration.

Comparative Efficacy of 9 Major Drugs for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: A Network Meta-Analysis.

BACKGROUND: Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is one of the most common complications after ERCP. The optimal drugs for reducing the risk of PEP are still unclear. This study aimed to compare the efficacy of 9 major drugs used worldwide for the prevention of PEP through a network meta-analysis. METHODS: We conducted a systematic search of the literature up to October 2018 on PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov. Randomized controlled trials (RCTs) comparing allopurinol, diclofenac, gabexate (GAB), glyceryl trinitrate (GTN), indomethacin, nafamostat, octreotide, somatostatin, and ulinastatin for protection against PEP were included. RESULTS: Eighty-six randomized controlled trials involving 25,246 patients were included in this network meta-analysis. Results indicated that diclofenac, GAB, GTN, indomethacin, somatostatin, and ulinastatin were more effective than placebo with odds ratios ranging between 0.48 (95% credible interval, 0.26-0.86) for GAB and 0.61 (0.39-0.94) for somatostatin. However, allopurinol, nafamostat, and octreotide showed similar efficacy as placebo in reducing the risk of PEP. No significant differences were found in the efficacy between diclofenac, GAB, GTN, indomethacin, somatostatin, and ulinastatin. In terms of prognosis, GAB may be the most effective treatment (surface under the cumulative ranking curve=70.6%) and the least effective was octreotide (surface under the cumulative ranking curve=28%). CONCLUSIONS: Although our analysis suggests that GAB may be the most effective drug in preventing PEP, the limitations of our study warrants more high-quality head-to-head trials of these clinical drugs in the future.

Minimally Invasive Versus Open Pancreaticoduodenectomy: An Up-to-Date Meta-Analysis of Comparative Cohort Studies.

BACKGROUND: This systematic review and meta-analysis were performed to summarize available evidence comparing totally minimally invasive pancreaticoduodenectomy (TMIPD) versus open pancreaticoduodenectomy (OPD) Materials and Methods: We searched PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for comparative cohort studies published from January 1990 through April 2018 comparing TMIPD versus OPD. Outcomes evaluated were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postoperative hemorrhage, wound infection, estimated blood loss, transfusion rate, retrieved lymph nodes (RLNs), R0 rate, reoperation rate, length of hospital stay, and mortality. Statistical analysis was performed with Review Manager, version 5.3 (Cochrane Collaboration). RESULTS: Sixteen comparative studies were included. Meta-analysis showed no significant difference between TMIPD and OPD in rates of POPF (risk ratio [RR] = 0.80; 95% confidence interval [CI]: 0.58-1.11; P = .18), DGE (RR = 0.80; 95% CI: 0.63-1.01; P = .06), postoperative hemorrhage (RR = 1.32; 95% CI: 0.87-2.00; P = .19), or reoperation (RR = 0.68; 95% CI: 0.45-1.05; P = .08). TMIPD resulted in fewer wound infections (RR = 0.49; 95% CI: 0.33-0.74; P = .0006), less blood loss (mean difference [MD] = 371.65 mL; 95% CI: -473.77 to -269.53; P < .00001), and lower transfusion rate (RR = 0.59; 95% CI: 0.48-0.72; P < .00001) than OPD. No significant differences were found in the rate of R0 resection (P = .32), RLNs (P = .09), hospital stay (P = .73), or mortality (P = .67). However, TMIPD had much longer operative times than OPD (MD = 80.78 minutes; 95% CI: 29.25-132.31; P = .002). CONCLUSION: TMIPD appears to be as safe and effective as OPD for periampullary disease. These findings need confirmation with large volume well-designed randomized controlled trials.

Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis.

BACKGROUND: The purpose of the study was to compare the safety and effectiveness of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) with preoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (pre-ERCP+LC) for cholecystocholedocholithiasis. METHODS: An electronic search was performed using the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 July 2018. Randomized controlled trials (RCTs) comparing LCBDE+LC versus pre-ERCP+LC were included. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative pancreatitis, morbidity, mortality, and overall hospital stay were analyzed. RESULTS: Twelve RCTs involving 1545 patients were included in this meta-analysis. Of the 12 RCTs, seven confirmed and five did not confirm CBD stones preoperatively. The meta-analysis showed a significantly higher CBD stone clearance rate for pre-ERCP+LC than LCBDE+LC. A similar result was found in the subgroup analysis of patients with confirmed CBD stones. A significantly lower postoperative bile leakage rate was found for pre-ERCP+LC than LCBDE+LC in all 12 RCTs and in the subgroup of patients with confirmed CBD stones. However, a significantly higher rate of pancreatitis was found in pre-ERCP+LC and in the subgroup of patients with confirmed CBD stones. LCBDE+LC was superior to pre-ERCP+LC in terms of the overall hospital stay. No significant differences were found in morbidity or mortality. CONCLUSIONS: Pre-ERCP+LC is associated with a higher CBD stone clearance rate, lower postoperative bile leakage rate, and higher rate of pancreatitis. LCBDE+LC might help to shorten the hospital stay. Further studies on this topic are recommended.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis.

BACKGROUND: The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP). METHODS: We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom). RESULTS: This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%). CONCLUSION: This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.