RESUMEN
BACKGROUND: Endoscopic transmural necrosectomy (ETN) is emerging as a viable treatment option for walled-off pancreatic necrosis. This NOTES-type procedure is significantly less invasive than an extensive surgical debridement; however, published data regarding the success of ETN in treating pancreatic necrosis have varied. OBJECTIVE: To evaluate the published medical literature to determine the success of treating walled-off pancreatic necrosis with ETN. METHODS: Studies using ETN as a primary mode of therapy to treat organized pancreatic necrosis were selected. Success was defined as resolution of the necrotic cavity proven by radiology. Articles were searched in Medline, PubMed, Ovid journals, CINAH, old Medline, Medline nonindexed citations and the Cochrane controlled trials registry. The summary estimates were expressed as pooled proportions. First, the individual study proportions were transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion was calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model. Publication bias was calculated using the Begg-Mazumdar and Harbord bias estimators. RESULTS: The initial search identified 920 reference articles, of which 129 relevant articles were selected and reviewed. Data were extracted from eight studies (n=233) that met the inclusion criteria. Organization of pancreatic necrosis was determined by computed tomography scan in all of the studies. The mean time of ETN after onset of acute pancreatitis/abdominal pain was seven weeks. The weighted mean size of the necrotic cavity was 12.87 cm (95% CI 10.54 cm to 15.20 cm). The weighted mean number of endoscopic procedures needed to resolve the necrotic cavity was 4.09 (95% CI 2.31 to 5.87). Pooled proportion of successful resolution of pancreatic necrosis using ETN was 81.84% (95% CI 76.73% to 86.44%). The pooled proportion of recurrence in the form of necrotic cavity or pseudocyst after ETN was 10.88% (95% CI 7.27% to 15.11%). Complications were noted in 21.33% (95% CI 16.40% to 26.72%) of patients and included bleeding, sepsis and perforation. The weighted mean number of days in hospital after ETN was 32.85 days (95% CI 10.50 to 55.20 days). For pancreatic necrosis that did not resolve, surgery had to be performed in 12.98% (95% CI 9.05% to 17.51%) of patients. The fixed-effect model was used to report all of the pooled proportions. Estimates calculated using fixed- and random-effects models were similar. Test of heterogeneity yielded P>0.10, indicating that the studies could be combined. The publication bias calculated using Begg-Mazumdar bias indicator yielded a Kendall's tau b value of -0.07 (P=0.72) and the same using Harbord bias indicator gave a value of 0.33 (95% CI -1.35 to 2.01; P=0.60). Both of these indicators show that there was no publication bias. CONCLUSION: The present meta-analysis showed that ETN is safe and effective at treating patients with symptomatic walled-off necrosis. ETN offers the advantage of minimally invasive endoscopic treatment without transabdominal surgery; however, better techniques and equipment are still needed to improve procedural efficiency. Decisions to perform ETN should be made by advanced endoscopists in collaboration with a multidisciplinary team with the facilities and personnel to manage these complex patients.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Desbridamiento , Cirugía Endoscópica por Orificios Naturales , Enfermedades Pancreáticas/cirugía , Colangiopancreatografia Retrógrada Endoscópica/métodos , Ensayos Clínicos como Asunto , Desbridamiento/métodos , Endosonografía , Medicina Basada en la Evidencia , Humanos , Comunicación Interdisciplinaria , Cirugía Endoscópica por Orificios Naturales/métodos , Necrosis , Pancreatectomía/métodos , Enfermedades Pancreáticas/diagnóstico por imagen , Enfermedades Pancreáticas/patología , Pancreatitis Aguda Necrotizante/cirugía , Reproducibilidad de los Resultados , Resultado del TratamientoRESUMEN
BACKGROUND: Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction. STUDY SELECTION CRITERIA: Studies using stents for palliation in patients with malignant hilar obstruction were selected. DATA COLLECTION AND EXTRACTION: Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. STATISTICAL METHODS: Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables 1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.
Asunto(s)
Neoplasias de los Conductos Biliares/cirugía , Colangiocarcinoma/cirugía , Colestasis/cirugía , Ictericia Obstructiva/cirugía , Stents , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/patología , Colestasis/patología , Hepatectomía , Humanos , Ictericia Obstructiva/patología , Trasplante de Hígado , Cuidados PaliativosRESUMEN
AIM: To detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs. METHODS: Only EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model). RESULTS: Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSION: EUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.