AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last up...AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P < 0.00001) and fewer re-interventions(21.6% vs 56.6%, P < 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P < 0.0001), with a higher patency period(250 d vs 124 d, P < 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P < 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.展开更多
Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERC...Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERCP(BEA-ERCP) is a safe and effective procedure.However,further improvements in outcomes and the development of simplified procedures are required.Percutaneous treatment,Laparoscopy-assisted ERCP,endoscopic ultrasoundguided anterograde intervention,and open surgery are effective treatments.However,treatment should be noninvasive,effective,and safe.We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications.BEA-ERCP still requires high expertiselevel techniques and is far from a routinely performed procedure.Various techniques have been proposed to facilitate scope insertion(insertion with percutaneous transhepatic biliary drainage(PTBD) rendezvous technique,Short type single-balloon enteroscopes with passive bending section,Intraluminal injection of indigo carmine,CO2 inflation guidance),cannulation(PTBD or percutaneous transgallbladder drainage rendezvous technique,Dilation using screw drill,Rendezvous technique combining DBE with a cholangioscope,endoscopic ultrasound-guided rendezvous technique),and treatment(overtube-assisted technique,Short type balloon enteroscopes) during BEA-ERCP.The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients.A standard procedure for ERCP yet to be established for patients with a reconstructed intestine.At present,BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as firstline treatment.In this article,we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.展开更多
The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing va...The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease.In this review,relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension.The main areas covered are safety of endoscopy in patients with liver disease,the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound,esophageal capsule,argon plasma coagulation,spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology.It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices.As the technology in endoscopy expands,so does the role of the endoscopist in liver disease.展开更多
Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bili...Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.展开更多
Primary sclerosing cholangitis （PSC） is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammat...Primary sclerosing cholangitis （PSC） is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammatory bowel disease （IBD）. A number of complications can occur which require special consideration, the most important of which is the development of cholangiocellular carcinoma （CCC）. Unfortunately, no medical therapy is currently available for the underlying liver disease. Liver transplantation is an effective, life-extending option for patients with advanced PSC. Geographical variations between East and West include a second peak for age with a lower association with IBD in a .lapanese population and female predominance in a lone study from Turkey. The clinical and biochemical Mayo criteria may not be universally applicable, as different patients show variations regarding the initial presentation and natural course of the disease, Directing research towards explaining these geographical differences and understanding the pathogenesis of PSC is required in order to develop better therapies for this devastating disease.展开更多
The clinical outcome of patients receiving liver trans-plantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these con-d...The clinical outcome of patients receiving liver trans-plantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these con-ditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications(mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasound-guided biliary access in patients with Roux-en-Y choledocho-jejunostomy or extracorporeal shock wave lithotripsy for difficult stones.展开更多
The single-balloon enteroscopy(SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy(DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. Howev...The single-balloon enteroscopy(SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy(DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.展开更多
Biliary complications are being increasingly encounteredin post liver transplant patients because ofincreased volume of transplants and longer survivalof these recipients. Overall management of thesecomplications may ...Biliary complications are being increasingly encounteredin post liver transplant patients because ofincreased volume of transplants and longer survivalof these recipients. Overall management of thesecomplications may be challenging, but with advancesin endoscopic techniques, majority of such patientsare being dealt with by endoscopists rather than thesurgeons. Our review article discusses the recent advancesin endoscopic tools and techniques that haveproved endoscopic retrograde cholangiography withvarious interventions, like sphincterotomy, bile ductdilatation, and stent placement, to be the mainstay formanagement of most of these complications. We alsodiscuss the management dilemmas in patients withsurgically altered anatomy, where accessing the bile ductis challenging, and the recent strides towards makingthis prospect a reality.展开更多
文摘AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P < 0.00001) and fewer re-interventions(21.6% vs 56.6%, P < 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P < 0.0001), with a higher patency period(250 d vs 124 d, P < 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P < 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.
文摘Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERCP(BEA-ERCP) is a safe and effective procedure.However,further improvements in outcomes and the development of simplified procedures are required.Percutaneous treatment,Laparoscopy-assisted ERCP,endoscopic ultrasoundguided anterograde intervention,and open surgery are effective treatments.However,treatment should be noninvasive,effective,and safe.We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications.BEA-ERCP still requires high expertiselevel techniques and is far from a routinely performed procedure.Various techniques have been proposed to facilitate scope insertion(insertion with percutaneous transhepatic biliary drainage(PTBD) rendezvous technique,Short type single-balloon enteroscopes with passive bending section,Intraluminal injection of indigo carmine,CO2 inflation guidance),cannulation(PTBD or percutaneous transgallbladder drainage rendezvous technique,Dilation using screw drill,Rendezvous technique combining DBE with a cholangioscope,endoscopic ultrasound-guided rendezvous technique),and treatment(overtube-assisted technique,Short type balloon enteroscopes) during BEA-ERCP.The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients.A standard procedure for ERCP yet to be established for patients with a reconstructed intestine.At present,BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as firstline treatment.In this article,we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.
文摘The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease.In this review,relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension.The main areas covered are safety of endoscopy in patients with liver disease,the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound,esophageal capsule,argon plasma coagulation,spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology.It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices.As the technology in endoscopy expands,so does the role of the endoscopist in liver disease.
文摘Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.
文摘Primary sclerosing cholangitis （PSC） is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammatory bowel disease （IBD）. A number of complications can occur which require special consideration, the most important of which is the development of cholangiocellular carcinoma （CCC）. Unfortunately, no medical therapy is currently available for the underlying liver disease. Liver transplantation is an effective, life-extending option for patients with advanced PSC. Geographical variations between East and West include a second peak for age with a lower association with IBD in a .lapanese population and female predominance in a lone study from Turkey. The clinical and biochemical Mayo criteria may not be universally applicable, as different patients show variations regarding the initial presentation and natural course of the disease, Directing research towards explaining these geographical differences and understanding the pathogenesis of PSC is required in order to develop better therapies for this devastating disease.
文摘The clinical outcome of patients receiving liver trans-plantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these con-ditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications(mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasound-guided biliary access in patients with Roux-en-Y choledocho-jejunostomy or extracorporeal shock wave lithotripsy for difficult stones.
文摘The single-balloon enteroscopy(SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy(DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.
文摘Biliary complications are being increasingly encounteredin post liver transplant patients because ofincreased volume of transplants and longer survivalof these recipients. Overall management of thesecomplications may be challenging, but with advancesin endoscopic techniques, majority of such patientsare being dealt with by endoscopists rather than thesurgeons. Our review article discusses the recent advancesin endoscopic tools and techniques that haveproved endoscopic retrograde cholangiography withvarious interventions, like sphincterotomy, bile ductdilatation, and stent placement, to be the mainstay formanagement of most of these complications. We alsodiscuss the management dilemmas in patients withsurgically altered anatomy, where accessing the bile ductis challenging, and the recent strides towards makingthis prospect a reality.
