Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation.

BACKGROUND AND AIMS: Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear. PATIENTS AND METHODS: This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events. RESULTS: Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69). CONCLUSIONS: NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Value of enhanced recovery after surgery in patients undergoing endoscopic retrograde cholangiopancreatography with intravenous anaesthesia for choledocholithiasis: a retrospective observational study.

Introduction: Enhanced recovery after surgery (ERAS) is rarely used in minimally invasive endoscopic surgery, especially in endoscopic retrograde cholangiopancreatography (ERCP). Aim: This study evaluated the safety and efficacy of the ERAS protocol in patients undergoing ERCP for choledocholithiasis. Material and methods: The study had a retrospective design and included patients with biliary tract stones who underwent ERCP between June 2019 and November 2022. Patients who received the ERAS protocol between June 2021 and November 2022 were enrolled as an ERAS group, and those who received traditional perioperative treatment between December 2019 and May 2021 were enrolled as a control group. Results: A total of 349 patients were enrolled (ERAS group, n = 185; control group, n = 164). The cannulation and stone extraction success rates were significantly higher in the ERAS group than in the control group (p < 0.05). The incidence of postoperative pancreatitis was significantly lower in the ERAS group (p = 0.02), but there were no significant differences in other complications. The postoperative hospital stay was significantly shorter in the ERAS group than in the control group (p < 0.001), with no statistically significant differences in costs according to surgical period, or in total costs, between the 2 groups. Conclusions: Application of the ERAS protocol is safe and feasible in patients undergoing ERCP for choledocholithiasis. The ERAS protocol can accelerate recovery, reduce postoperative pain, and shorten the hospital stay without increasing the cost of treatment.

The Predictive Value of Different Laboratory Indicators Based on the 2018 Tokyo Guidelines for the Severity of Acute Cholangitis.

BACKGROUND: This study evaluated the predictive value of different laboratory indicators for the severity of acute cholangitis (AC) according to the 2018 Tokyo Guidelines. OBJECTIVES: We enrolled consecutive patients with a diagnosis of AC from June 2016 to May 2021. Serum procalcitonin (PCT) and C-reactive protein (CRP) levels, white blood cell counts, the neutrophil-lymphocyte ratio, and the platelet-lymphocyte ratio (PLR) were compared according to the severity of AC. RESULTS: In total, 293 patients were enrolled in this study (mild, n = 172; moderate, n = 68; severe, n = 53). In receiver operating characteristic analyses, CRP was the best biomarker for differentiating mild and moderate AC (area under the curve [AUC] 0.66, 95% confidence interval [CI] 0.58-0.74). PCT was the best biomarker for differentiating mild and severe AC (AUC 0.80, 95% CI 0.74-0.86). Blood culture was performed in 117 patients (39.93%), 53 of whom (45.30%) had positive results. Regarding blood culture positivity, PLR was most predictive (AUC 0.85, 95% CI 0.78-0.92). CONCLUSIONS: PCT can be used as a reliable predictor of severe AC. CRP was most predictive of moderate AC, whereas PLR was most predictive of blood culture positivity.

Comparison of metal versus plastic stent for preoperative biliary drainage in patients with pancreatic cancer undergoing neoadjuvant therapy: a meta-analysis and systematic review.

BACKGROUND: This study was performed to compare a metal stent (MS) and plastic stent (PS) in terms of efficacy and complications during neoadjuvant therapy (NAT) and the perioperative period. METHODS: We performed an electronic search of the following databases until 1 June 2022: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Studies comparing an MS versus PS for PBD in patients with pancreatic cancer undergoing NAT were included. RESULTS: The meta-analysis showed that use of an MS was associated with lower rates of reintervention (p < 0.00001), delay of NAT (p = 0.007), recurrent biliary obstruction (RBO) (p = 0.003), and cholangitis (p = 0.03). There were no significant differences between the two groups in terms of stent migration (p = 0.31), postoperative complications (p = 0.20), leakage (p = 0.90), and R0 resection (p = 0.50). CONCLUSIONS: Use of an MS for PBD in patients with pancreatic cancer undergoing NAT followed by surgery was associated with lower rates of reintervention, delay of NAT, RBO, and cholangitis compared with use of a PS. However, the postoperative outcomes were comparable between the MS and PS. Further studies on this topic are recommended.

Early is Not Superior to Late Endoscopic Intervention for Acute Cholangitis.

BACKGROUND: Acute cholangitis (AC) is a common emergency with a significant mortality risk. This study aimed to compare urgent, early, and late endoscopic retrograde cholangiopancreatography (ERCP) for AC. METHOD: We retrospectively evaluated patients diagnosed with AC from June 2016 to May 2021. According to the time of ERCP, patients were divided into urgent (≤24 h), early (24-48 h), and late (≥48 h) groups. Primary outcomes were technical success, in-hospital mortality, and 30-day mortality. Secondary outcomes were the length of hospital stay (LOS), ERCP-related adverse events, and 30-day readmission. RESULTS: We divided 121 patients who underwent ERCP into urgent (N = 15), early (N = 19), and late groups (N = 87). There was no in-hospital mortality and no significant difference in technical success (93.3% (urgent) vs 89.5% (early) vs 96.6% (late); P = .41) and 30-day mortality (P = .82). LOS in the urgent and early groups was shorter than that in the late group (13.93 days vs 8.82 days vs 14.20 days, respectively; P = .02). There was no difference between groups for ERCP-related adverse events and 30-day readmission rates. CONCLUSIONS: Urgent or early ERCP was not superior to late ERCP for technical success and 30-day mortality. However, urgent or early ERCP was associated with shorter LOS than late ERCP.

Comparison between Transpancreatic Sphincterotomy and Needle-Knife Precut in Difficult Cannulation of Endoscopic Retrograde Cholangiopancreatography: An Up-To-Date Meta-Analysis and Systematic Review.

BACKGROUND: Selective cannulation, which is essential for endoscopic retrograde cholangiopancreatography (ERCP), may be difficult. The aim of this study was to compare transpancreatic sphincterotomy (TPS) and needle-knife precut (NKP) in difficult cannulation during ERCP. METHODS: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for relevant studies from January 1990 to April 2022. A meta-analysis focusing on cannulation success and post-ERCP complications was performed using Review Manager. RESULTS: Seventeen eligible studies involving 2,340 patients were included. Our results showed that the TPS group had a higher cannulation success rate (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.27-0.87, p = 0.02) and less bleeding (OR 1.94, 95% CI: 1.09-3.47, p = 0.03) compared with the NKP group. There was no significant difference between NKP and TPS in the rates of post-ERCP pancreatitis (OR 0.83, 95% CI: 0.59-1.18, p = 0.30), perforation (OR 2.04, 95% CI: 0.69-6.03, p = 0.20), and adverse events (OR 1.29, 95% CI: 0.94-1.77, p = 0.12). CONCLUSION: TPS appears to be associated with a higher cannulation success rate and less bleeding than those with NKP, with equal post-ERCP pancreatitis, perforation, and adverse event rates between TPS and NKP. Further large-scale trials are warranted to support our findings.

Outcomes of delayed versus early endoscopic intervention for acute biliary pancreatitis with non-severe acute cholangitis.

BACKGROUND: Despite previous studies on endoscopic interventions in patients with acute biliary pancreatitis (ABP), the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) for ABP with non-severe acute cholangitis (AC) remains controversial. METHODS: We performed a retrospective cohort analysis of patients with concurrent ABP and non-severe AC. The patients were divided into two groups: those who underwent ERCP ≤ 72 h after admission (early ERCP group) and those who underwent ERCP > 72 h after admission (delayed ERCP group). The primary outcomes were the technical success rate and ERCP-related complications. RESULTS: The study involved 164 patients (early ERCP, n = 70; delayed ERCP, n = 94) who were treated from 1 December 2 to 2016 to 12 December 2021. The patients' baseline characteristics were not significantly different between the two groups. The technical success rate of ERCP was similar between the two groups (94.29% vs. 97.87%, p = 0.43). Morbidity was also similar between the two groups (p = 0.83). There was no significant difference in the total hospital stay (p = 0.13). However, the early ERCP group had a longer post-ERCP hospital stay (p < 0.001). CONCLUSION: This retrospective analysis showed that delayed ERCP performed > 72 h after admission has economic and safety outcomes similar to those of early ERCP for patients with concurrent ABP and non-severe AC.

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.

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.

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.

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.

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 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.

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 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.