BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct...BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi(PDC)in chronic pancreatitis.POP uses two techniques:Electrohydraulic lithotripsy(EHL)and laser lithotripsy(LL).Data on the safety and efficacy are limited for this procedure.We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP.The secondary aim was to assess pooled rates of technical success,clinical success for the two individual techniques,and adverse event rates.AIM To perform a systematic review and meta-analysis of POP,EHL and LL for management of PDC in chronic pancreatitis.METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed,EMBASE,Cochrane,Google Scholar and Web of Science databases(from 1999 to October 2019)to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP,EHL and LL.The primary outcome assessed involved the pooled technical success and clinical success rate of POP.The secondary outcome included the pooled technical success and clinical success rate for EHL and LL.We also assessed the pooled rate of adverse events for POP,EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP:Hemorrhage,post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP),perforation,abdominal pain,fever and infections.Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain.Randomeffects model was used for analysis.Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics.Publication bias was ascertained,qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTS A total of 16 studies including 383 patients met the inclusion criteria.The technical success rate of POP was 76.4%(95%CI:65.9-84.5;I2=64%)and clinical success rate was 76.8%(95%CI:65.2-85.4;I2=66%).The technical success rate of EHL was 70.3%(95%CI:57.8-80.3;I2=36%)and clinical success rate of EHL was 66.5%(95%CI:55.2-76.2;I2=19%).The technical success rate of LL was 89.3%(95%CI:70.5-96.7;I2=70%)and clinical success rate of LL was 88.2%(95%CI:66.4-96.6;I2=77%).The incidence of pooled adverse events for POP was 14.9%(95%CI:9.2-23.2;I2=49%),for EHL was 11.2%(95%CI:5.9-20.3;I2=15%)and for LL was 13.1%(95%CI:6.3-25.4;I2=31%).Subgroup analysis of adverse events showed rates of PEP at 7%(95%CI:3.5-13.6;I2=38%),fever at 3.7%(95%CI:2-6.9;I2=0),abdominal pain at 4.7%(95%CI:2.7-7.8;I2=0),perforation at 4.3%(95%CI:2.1-8.4;I2=0),hemorrhage at 3.4%(95%CI:1.7-6.6;I2=0)and no mortality.There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSION Our study highlights the high technical and clinical success rates for POP,EHL and LL.POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.展开更多
BACKGROUND Liver transplantation is the accepted standard of care for end-stage liver disease due to a variety of etiologies including decompensated cirrhosis, fulminant hepatic failure, and primary hepatic malignancy...BACKGROUND Liver transplantation is the accepted standard of care for end-stage liver disease due to a variety of etiologies including decompensated cirrhosis, fulminant hepatic failure, and primary hepatic malignancy. There are currently over 13000 candidates on the liver transplant waiting list emphasizing the importance of rigorous patient selection. There are few studies regarding the impact of additional psychosocial barriers to liver transplant including financial hardship, lack of caregiver support, polysubstance abuse, and issues with medical noncompliance. We hypothesized that patients with certain psychosocial comorbidities experienced worse outcomes after liver transplantation. AIM To assess the impact of certain pre-transplant psychosocial comorbidities on outcomes after liver transplantation. METHODS A retrospective analysis was performed on all adult patients from 2012-2016. Psychosocial comorbidities including documented medical non-compliance, polysubstance abuse, financial issues, and lack of caregiver support were collected. The primary outcome assessed post-transplantation was survival. Secondary outcomes measured included graft failure, episodes of acute rejection, psychiatric decompensation, number of readmissions, presence of infection, recidivism for alcohol and other substances, and documented caregiver support failure.RESULTS For the primary outcome, there were no differences in survival. Patients with a history of psychiatric disease had a higher incidence of psychiatric decompensation after liver transplantation (19% vs 10%, P = 0.013). Treatment of psychiatric disorders resulted in a reduction of the incidence of psychiatric decompensation (21% vs 11%, P = 0.022). Patients with a history of polysubstance abuse in the transplant evaluation had a higher incidence of substance abuse after transplantation (5.8% vs 1.2%, P = 0.05). In this cohort, 15 patients (3.8%) were found to have medical compliance issues in the transplant evaluation. Of these specific patients, 13.3% were found to have substance abuse after transplantation as opposed to 1.3% in patients without documented compliance issues (P = 0.03). CONCLUSION Patients with certain psychosocial comorbidities had worse outcomes following liver transplantation. Further prospective and multi-center studies are warranted to properly determine guidelines for liver transplantation regarding this highrisk population.展开更多
文摘BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi(PDC)in chronic pancreatitis.POP uses two techniques:Electrohydraulic lithotripsy(EHL)and laser lithotripsy(LL).Data on the safety and efficacy are limited for this procedure.We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP.The secondary aim was to assess pooled rates of technical success,clinical success for the two individual techniques,and adverse event rates.AIM To perform a systematic review and meta-analysis of POP,EHL and LL for management of PDC in chronic pancreatitis.METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed,EMBASE,Cochrane,Google Scholar and Web of Science databases(from 1999 to October 2019)to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP,EHL and LL.The primary outcome assessed involved the pooled technical success and clinical success rate of POP.The secondary outcome included the pooled technical success and clinical success rate for EHL and LL.We also assessed the pooled rate of adverse events for POP,EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP:Hemorrhage,post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP),perforation,abdominal pain,fever and infections.Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain.Randomeffects model was used for analysis.Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics.Publication bias was ascertained,qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTS A total of 16 studies including 383 patients met the inclusion criteria.The technical success rate of POP was 76.4%(95%CI:65.9-84.5;I2=64%)and clinical success rate was 76.8%(95%CI:65.2-85.4;I2=66%).The technical success rate of EHL was 70.3%(95%CI:57.8-80.3;I2=36%)and clinical success rate of EHL was 66.5%(95%CI:55.2-76.2;I2=19%).The technical success rate of LL was 89.3%(95%CI:70.5-96.7;I2=70%)and clinical success rate of LL was 88.2%(95%CI:66.4-96.6;I2=77%).The incidence of pooled adverse events for POP was 14.9%(95%CI:9.2-23.2;I2=49%),for EHL was 11.2%(95%CI:5.9-20.3;I2=15%)and for LL was 13.1%(95%CI:6.3-25.4;I2=31%).Subgroup analysis of adverse events showed rates of PEP at 7%(95%CI:3.5-13.6;I2=38%),fever at 3.7%(95%CI:2-6.9;I2=0),abdominal pain at 4.7%(95%CI:2.7-7.8;I2=0),perforation at 4.3%(95%CI:2.1-8.4;I2=0),hemorrhage at 3.4%(95%CI:1.7-6.6;I2=0)and no mortality.There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSION Our study highlights the high technical and clinical success rates for POP,EHL and LL.POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.
文摘BACKGROUND Liver transplantation is the accepted standard of care for end-stage liver disease due to a variety of etiologies including decompensated cirrhosis, fulminant hepatic failure, and primary hepatic malignancy. There are currently over 13000 candidates on the liver transplant waiting list emphasizing the importance of rigorous patient selection. There are few studies regarding the impact of additional psychosocial barriers to liver transplant including financial hardship, lack of caregiver support, polysubstance abuse, and issues with medical noncompliance. We hypothesized that patients with certain psychosocial comorbidities experienced worse outcomes after liver transplantation. AIM To assess the impact of certain pre-transplant psychosocial comorbidities on outcomes after liver transplantation. METHODS A retrospective analysis was performed on all adult patients from 2012-2016. Psychosocial comorbidities including documented medical non-compliance, polysubstance abuse, financial issues, and lack of caregiver support were collected. The primary outcome assessed post-transplantation was survival. Secondary outcomes measured included graft failure, episodes of acute rejection, psychiatric decompensation, number of readmissions, presence of infection, recidivism for alcohol and other substances, and documented caregiver support failure.RESULTS For the primary outcome, there were no differences in survival. Patients with a history of psychiatric disease had a higher incidence of psychiatric decompensation after liver transplantation (19% vs 10%, P = 0.013). Treatment of psychiatric disorders resulted in a reduction of the incidence of psychiatric decompensation (21% vs 11%, P = 0.022). Patients with a history of polysubstance abuse in the transplant evaluation had a higher incidence of substance abuse after transplantation (5.8% vs 1.2%, P = 0.05). In this cohort, 15 patients (3.8%) were found to have medical compliance issues in the transplant evaluation. Of these specific patients, 13.3% were found to have substance abuse after transplantation as opposed to 1.3% in patients without documented compliance issues (P = 0.03). CONCLUSION Patients with certain psychosocial comorbidities had worse outcomes following liver transplantation. Further prospective and multi-center studies are warranted to properly determine guidelines for liver transplantation regarding this highrisk population.
