Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM:To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography(ERCP).METHODS:PubMed,Embase,Science Citation Index,and Cochrane Controlled Trials Register were searched to identify relevant trials published in English.Inclu-sion and exclusion criteria were used to screen for suitable studies.Two reviewers independently judged the study eligibility while screening the citations.The methodological quality of the included trials was assessed using the Jadad scoring system.All results were expressed as OR and 95%CI.Data were analyzed using Stata12.0 software.RESULTS:Ten eligible randomized controlled trials were selected,including 1176 patients.A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of postERCP pancreatitis(PEP)in high-risk patients(OR=0.25;95%CI:0.17-0.38;P<0.001).Pancreatic stents also alleviated the severity of PEP(mild pancreatitis after ERCP:OR=0.33;95%CI:0.21-0.54;P<0.001;moderate pancreatitis after ERCP:OR=0.30;95%CI:0.13-0.67;P=0.004).The result of severe pancreatitis after ERCP was handled more rigorously(OR=0.24;95%CI:0.05-1.16;P=0.077).Serum amylase levels were not different between patients with pancreatic stents and control patients(OR=1.08;95%CI:0.82-1.41;P=0.586).CONCLUSION:Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.     

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P=0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P=0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P=0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P=0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P=0.00). CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.     

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation

AIM: To investigate the need for pancreatic stenting after endoscopic sphincterotomy (EST) in patients with difficult biliary cannulation.METHODS: Between April 2008 and August 2013, 2136 patients underwent endoscopic retrograde cholangiopancreatography (ERCP)-related procedures. Among them, 55 patients with difficult biliary cannulation who underwent EST after bile duct cannulation using the pancreatic duct guidewire placement method (P-GW) were divided into two groups: a stent group (n = 24; pancreatic stent placed) and a no-stent group (n = 31; no pancreatic stenting). We retrospectively compared the two groups to examine the need for pancreatic stenting to prevent post-ERCP pancreatitis (PEP) in patients undergoing EST after biliary cannulation by P-GW.RESULTS: No differences in patient characteristics or endoscopic procedures were observed between the two groups. The incidence of PEP was 4.2% (1/24) and 29.0% (9/31) in the Stent and no-stent groups, respectively, with the no-stent group having a significantly higher incidence (P = 0.031). The PEP severity was mild for all the patients in the stent group. In contrast, 8 had mild PEP and 1 had moderate PEP in the no-stent group. The mean serum amylase levels (means ± SD) 3 h after ERCP (183.1 ± 136.7 vs 463.6 ± 510.4 IU/L, P = 0.006) and on the day after ERCP (209.5 ± 208.7 vs 684.4 ± 759.3 IU/L, P = 0.002) were significantly higher in the no-stent group. A multivariate analysis identified the absence of pancreatic stenting (P = 0.045; odds ratio, 9.7; 95%CI: 1.1-90) as a significant risk factor for PEP.CONCLUSION: In patients with difficult cannulation in whom the bile duct is cannulated using P-GW, a pancreatic stent should be placed even if EST has been performed.     

Preoperative defining system for pancreatic head cancer considering surgical resection

AIM: To provide appropriate treatment, it is crucial to share the clinical status of pancreas head cancer among multidisciplinary treatment members. METHODS: A retrospective analysis of the medical records of 113 patients who underwent surgery for pancreas head cancer from January 2008 to December 2012 was performed. We developed preoperative defining system of pancreatic head cancer by describing "resectability- tumor location- vascular relationship- adjacent organ involvement- preoperative CA19-9(initial bilirubin level)- vascular anomaly". The oncologic correlations with this reporting system were evaluated.RESULTS: Among 113 patients, there were 75 patients(66.4%) with resectable, 34 patients(30.1%) with borderline resectable, and 4 patients(3.5%) with locally advanced pancreatic cancer. Mean disease-free survival was 24.8 mo(95%CI: 19.6-30.1) with a 5-year diseasefree survival rate of 13.5%. Pretreatment tumor size ≥ 2.4 cm [Exp(B) = 3.608, 95%CI: 1.512-8.609, P = 0.044] and radiologic vascular invasion [Exp(B) = 5.553, 95%CI: 2.269-14.589, P = 0.002] were independent predictive factors for neoadjuvant treatment. Borderline resectability [Exp(B) = 0.222, P = 0.008], pancreatichead cancer involving the pancreatic neck [Exp(B) = 9.461, P = 0.001] and arterial invasion [Exp(B) = 6.208, P = 0.010], and adjusted CA19-9 ≥ 50 [Exp(B) = 1.972 P = 0.019] were identified as prognostic clinical factors to predict tumor recurrence. CONCLUSION: The suggested preoperative defining system can help with designing treatment plans and also predict oncologic outcomes.     

Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma. METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage. RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage. CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.     

Comparative analysis of endoscopic precut conventional and needle knife sphincterotomy

AIM:To compare the efficacy,complications and postprocedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomie.METHODS:We performed a retrospective analysis of two pre-cut sphincterotomy(PS) techniques,pre-cut conventional sphincterotomy(PCS),and pre-cut needle knife(PNK).The study included 143 patients;the classic technique was used in 59 patients(41.3%),and the needle knife technique was used in 84 patients(58.7%).We analyzed the efficacy of bile duct access,the need for a two-step procedure,the rates of complications and hyperamylasemia 4 h after the procedure,"endoscopic bleeding" and the need for bleeding control.Furthermore,to assess whether the anatomy of the Vater’s papilla,indications for the procedure or the need for additional procedures could inform the choice of the PS method,we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables.RESULTS:The bile duct access efficacy with PNK and PCS was 100% and 96.6%,respectively,and the difference between the two groups was not significant(P = 0.06).However,the needle knife technique required two-step access significantly more often,in 48.8% vs8.5% of cases(P < 0.0001).The only complication noted was post-ercp pancreatitis(PEP),which was observed in 4/84(4.8%) and 2/59(3.4%) patients submitted to PNK and PSC,respectively;the difference between the two procedures was not significant(P = 0.98).An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups:hyperamylasemia 4 h after the procedure > 80 U/L,41/84 vs 23/59(P = 0.32);hyperamylasemia 4 h after the procedure > 240 U/L,19/84 vs 11/59(P = 0.71);pancreatic pain,13/84 vs 7/59(P = 0.71);endoscopic bleeding,10/84 vs 8/59(P = 0.97);and the need for bleeding control,10/84 vs 7/59(P = 0.79).In the next part of the study,we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancr     

ERCP术后胰腺炎的影响因素分析

目的探讨诊断性与治疗性ERCP术后引发AP的高危因素及防范措施。方法采用单因素及多因素变量分析方法，对54例行诊断与治疗性ERCP的患者进行队列研究。结果54例患者中，3例（5，6％）并发ERCP术后胰腺炎（PEP），其中1例为诊断性ERCP，2例为诊疗性ERCP，ERCP术后胰腺炎均为轻症，经内科综合治疗后均痊愈出院。与PEP相关的主要因素有多次插管、多次胰管造影、导丝多次进入胰管、导丝引导插管、术中腹痛、全胰管显影、既往有胰腺炎病史等。其中，多次插管、胰管多次造影以及术中腹痛为高危因素。结论PEP与患者自身因素及医师操作技术有关，有效避免或减少这些高危因素的发生可预防PEP。     

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND Previous studies have revealed that patients with asymptomatic common bile duct(CBD) stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP). However, no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.AIM To examine the risk factors for PEP in patients with asymptomatic CBD stones.METHODS Using medical records of three institutions in Japan for 6 years, we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP. We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.RESULTS The overall incidence rate of PEP in all the patients with during study period was4.7%(53/1135). Of the 168 patients with asymptomatic CBD stones, 24(14.3%)developed PEP. In univariate analysis, precut sphincterotomy(P = 0.009) and biliary balloon sphincter dilation(P = 0.043) were significant risk factors for PEP.In multivariate analysis, precut sphincterotomy(P = 0.002, 95%CI: 2.2-27.8, odds ratio = 7.7), biliary balloon sphincter dilation(P = 0.015, 95%CI: 1.4-17.3, odds ratio = 4.9), and trainee endoscopists(P = 0.048, 95%CI: 1.01-8.1, odds ratio = 2.9)were significant risk factors for PEP.CONCLUSION ERCP for asymptomatic CBD stones should be performed by experienced endoscopists. When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones, the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.     

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla

Background and Aim: Epinephrine sprayed on the papilla may reduce papillary edema and prevent acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to evaluate the effects of localized irrigation with epinephrine saline for prevention of post‐ERCP pancreatitis (PEP). Methods: A total of 941 patients who were scheduled for ERCP were recruited into this study. We randomized the patients to have 20 mL of either 0.02% epinephrine or saline sprayed on the papilla after diagnostic ERCP to prevent post‐ERCP pancreatitis. We recorded duct visualization, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. The serum amylase levels were measured at 6, 24 and 48 h after ERCP. We counted the patients of PEPs and compared whether there was significant difference between the pancreatitis group and the no pancreatitis group. Results: A univariate analysis of the explanatory variables between the epinephrine and control groups, the pancreatitis and no pancreatitis groups revealed the treatment to be effective, but most of the groups were not statistically significant. PEPs occurred in 40 of the 941 patients (4.25%), the incidence of pancreatitis tended to be higher in the control group (31/480, 6.45%) than in the epinephrine group (9/461, 1.95%) (P = 0.0086). Conclusions: Epinephrine sprayed on the papilla may be effective to prevent PEP. Female patients (aged ≥ 18 years and < 35 years) (7/40, 17.5%), common bile duct diameter < 10 mm (27/40, 67.5%), previous cholangitis (3/40, 7.5%), body mass index ≥ 24 (22/40, 55%), and/or serum triglycerides ≥ 5.65 mmol/L (6/40, 15%), might be risk factors for post‐ERCP pancreatitis, but are not statistically significant in the study.     

Indomethacin may reduce the incidence and severity of acute pancreatitis after ERCP

OBJECTIVES: Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Many medications have been used to prevent this complication. We aimed to evaluate the efficacy of rectally administered indomethacin for the prevention of post-ERCP pancreatitis. METHODS: During 18 months, all eligible patients who underwent ERCP were enrolled in this study. In a double-blind randomized trial, patients received a suppository containing indomethacin, 100 mg, or an inert placebo immediately before ERCP. Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP. RESULTS: A total of 490 patients entered the trial, of which half received indomethacin. Twenty-two patients developed pancreatitis; seven cases in the indomethacin group and 15 in the placebo group (P=0.06). Pancreatic duct injection (OR=3.0, 95% CI: 1.3-7.4), pancreatic duct cannulation more than once (OR=4.2, 95% CI: 1.7-10.0), and age less than 60 yr (OR=2.7, 95% CI: 1.0-7.1) were shown to be significant risk factors for developing post-ERCP pancreatitis. In patients who underwent pancreatography with or without cholangiography, the risk of pancreatitis was significantly lower in the indomethacin group compared with the control group (P=0.01, RRR=88%, ARR=0.16, NNT=6). Moderate to severe pancreatitis was significantly higher in the placebo group (P= 0.03). CONCLUSIONS: This trial shows that rectal indomethacin given immediately before ERCP can reduce the incidence and severity of post-ERCP pancreatitis.     

Impact of being overweight on the surgical outcomes of patients with gastric cancer: A meta-analysis

AIM: To investigate the effect of being overweight on the surgical results of patients with gastric cancer. METHODS: Comprehensive electronic searches of the PubMed, Web of Science, and Cochrane Library databases were conducted. Studies were identified that included patients with surgical complications from gastric cancer who were classified as normal weight [body mass index (BMI) < 25 kg/m 2 ] or overweight (BMI ≥ 25 kg/m 2 ). The operative time, retrieved lymph nodes, blood loss, and long-term survival were analyzed. A subgroup analysis was conducted based on whether patients received laparoscopic or open gastrectomy procedures. All statistical tests were performed using ReviewerManager 5.1.2 software. RESULTS: This meta-analysis included 23 studies with 20678 patients (15781 with BMI < 25 kg/m 2 ; 4897 with BMI ≥ 25 kg/m 2 ). Overweight patients had significantly increased operation times [MD: -29.14; 95%CI: -38.14-(-20.21); P < 0.00001], blood loss [MD: -194.58; 95%CI: -314.21-(-74.95); P = 0.001], complications (RR: 0.75; 95%CI: 0.66-0.85; P < 0.00001), anastomosis leakages (RR: 0.59; 95%CI: 0.42-0.82; P = 0.002), and pancreatic fistulas (RR: 0.486; 95%CI: 0.34-0.63; P < 0.00001), whereas lymph node retrieval was decreased significantly in the overweight group (MD: 1.69; 95%CI: 0.75-2.62; P < 0.0001). In addition, overweight patients had poorer long-term survival (RR: 1.14; 95%CI: 1.07-1.20; P < 0.0001). No significant difference was detected for the mortality and length of hospital stay. CONCLUSION: This meta-analysis demonstrates that a high BMI not only increases the surgical difficulty and complications but also impairs the long-term survival of patients with gastric cancer.     

联合应用质子泵抑制剂、生长抑素和加贝酯预防ERCP术后胰腺炎和高淀粉酶血症的临床研究

背景：急性胰腺炎和高淀粉酶血症是内镜逆行胰胆管造影术（ERCP）的主要并发症,术前用药对预防和减轻并发症的作用尚存争议。目的：探讨联合应用质子泵抑制剂、生长抑素和加贝酯对ERCP术后胰腺炎（PEP）和高淀粉酶血症的预防作用。方法：共纳入510例行ERCP的患者,随机分为加贝酯组、生长抑素组、联合治疗组（质子泵抑制剂＋生长抑素＋加贝酯）和安慰剂组。观察术后2h、12h和24h血清淀粉酶水平,评估PEP和高淀粉酶血症的发生率．并分析PEP和高淀粉酶血症的危险因素。结果：ERCP术后2h、12h、24h,联合治疗组、生长抑素组和加贝酯组血清淀粉酶水平显著低于安慰剂组（P〈0．05或P〈0．01）,联合治疗组血清淀粉酶水平亦显著低于生长抑素组或加贝酯组（P〈0．05）。ERCP胰管显影者的PEP和高淀粉酶血症发生率显著高于胆管显影者（P〈0．05）。单变量分析显示ERCP操作过程中胰管多次显影、导丝多次插入胰管、导丝辅助、反复插管以及操作中发生上腹疼痛为PEP和高淀粉酶血症的技术相关性高危因素。结论：ERCP术前后联合应用质子泵抑制剂、生长抑素和加贝酯可改善PEP和高淀粉酶血症的发生。     

Analysis of the risk factors for severity in post endoscopic retrograde cholangiopancreatography pancreatitis: The indication of prophylactic treatments

AIM To determine the risk factors of severe post endoscopic retrograde cholangiopancreatography pancreatitis(s PEP) and clarify the indication of prophylactic treatments.METHODS At our hospital, endoscopic retrograde cholangiopancreatography(ERCP) was performed on 1507 patients from May 2012 to December 2015. Of these patients, we enrolled all 121 patients that were diagnosed with post endoscopic retrograde PEP. Fourteen of 121 patients diagnosed as s PEP were analyzed.RESULTS Forty-one patients had contrast media remaining in the pancreatic duct after completion of ERCP. Seventy-one patients had abdominal pain within three hours after ERCP. These were significant differences for s PEP(P 0.05). The median of Body mass index, the median time for ERCP, the median serum amylase level of the next day, past histories including drinking and smoking, past history of pancreatitis, sphincter of Oddi dysfunction, whether emergency or not, expertise of ERCP procedure, diverticulum nearby Vater papilla, whether there was sphincterotomy or papillary balloon dilation, pancreatic duct cannulation, use of intraductal ultrasonography enforcement, and transpapillary biopsies had no significant differences with s PEP.CONCLUSION Contrast media remaining in the pancreatic duct and the appearance of abdominal pain within three hours after ERCP were risk factors of s PEP.     

A Multicenter, Randomized, Controlled Trial to Evaluate the Effect of Prophylactic Octreotide on ERCP-Induced Pancreatitis

Eight-four patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were randomized to receive 100 micrograms of octreotide intravenously immediately prior to ERCP, and 100 micrograms subcutaneously 45 min after the initial dose, or placebo. Amylase, lipase, and glucose were measured and clinical assessment was performed before, and 2 and 24 h after, ERCP. We define clinical pancreatitis as the combination of elevated amylase or lipase with abdominal pain and tenderness. Interim analysis in 84 patients revealed an 11% incidence of clinical pancreatitis in the control group and 35% in the treatment group (p < 0.01). There were no differences in either group with respect to sphincterotomy, gender, age, duration of ERCP, number of cannulations of the pancreatic duct, degree of duct injection, or the volume of contrast injected. Analysis of group differences stratified by sphincterotomy revealed the following: 1) In patients who did not undergo a sphincterotomy, there was a significantly higher rate of pancreatitis in the treatment group [10/17 (59%) versus 1/17 (6%) RR 10.0 (95% CI 1.4-69.8)]. 2) Sphincterotomy reduced the rate of pancreatitis in patients who received octreotide from 10/17 (59% no sphincterotomy), to 3/20 (15% sphincterotomy) (p = 0.01), which equals the rate in patients who received placebo and underwent sphincterotomy [4/25 (16%)]. 3) Although the incidence of pancreatitis was higher in the treatment group, octreotide may reduce the severity of pancreatitis measured by the number of days NPO (Wilcoxon rank sum, p = 0.02), length of stay after ERCP (p = 0.13), the number of days of pain (p = 0.11), and the degree of amylase elevation (p = 0.04). We conclude that: 1) Octreotide appears to increase the incidence of pancreatitis when given prophylactically for diagnostic ERCP. 2) Although pancreatitis was more common in the octreotide group, it was less severe than the placebo group. 3) Sphincterotomy may afford protection against pancreatitis in patients who received octreotide. 4) We cannot recommend the use of prophylactic octreotide during diagnostic or therapeutic ERCP.     

Effectiveness of nonsteroidal anti-in?ammatory drugs in prevention of post-ERCP pancreatitis: A meta-analysis

AIM: To investigate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).METHODS: Two independent reviewers searched PubMed (1966 to October 2013), Embase (1984 to October 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 4, 2013) for relevant randomized controlled trials (RCTs) studying the effectiveness of prophylactic NSAID administration in the prevention of PEP. Using the Cochrane Collaboration Handbook, meta-analyses were conducted to evaluate the overall effect of NSAIDs in preventing the incidences of PEP and moderate to severe pancreatitis.RESULTS: Eight RCTs were identified from the literature search and included 1883 patients that underwent ERCP, with 971 patients in the NSAID group and 912 patients in the placebo group. Sixty-nine out of 971 (7.11%) patients developed PEP in the NSAID group in comparison to 143 out of 912 (15.68%) patients in the placebo group. The pooled RR of PEP incidence with prophylactic NSAID administration was 0.43 (95%CI: 0.33-0.56), which demonstrates that NSAID administration after ERCP significantly reduced the incidence of PEP when compared to the placebo group (P < 0.0001). Subgroup analysis was performed and revealed that the presence (NSAID group) or absence (placebo group) of NSAIDs had no significant effect on the development of moderate to severe pancreatitis (RR = 0.79, 95%CI: 0.52-1.18). Moreover, the administration of NSAIDs as a rectal suppository (RR = 0.35, 95%CI: 0.26-0.48; P < 0.0001) was more effective than oral administration (RR = 0.97, 95%CI: 0.53-1.80) or through infusion (RR = 0.43, 95%CI: 0.12-1.54).CONCLUSION: NSAIDs effectively reduce the incidence of PEP but not of moderate to severe pancreatitis.     

ABO blood type,long-standing diabetes,and the risk of pancreatic cancer

AIM: To retrospectively study pancreatic cancer patients with respect to their ABO blood type and diabetes. METHODS: Our analysis included a cohort of 1017 patients with pancreatic ductal cancer diagnosed at our hospital in Tokyo. They were divided into two groups: 114 patients with long-standing type 2 diabetes (DM group, defined as diabetes lasting for at least three years before the diagnosis of pancreatic cancer) and 903 patients without diabetes (non-DM group). Multivariate analysis was performed to identify factors that are associated with long-standing diabetes. The DM group was further divided into three subgroups according to the duration of diabetes (3-5 years, 5.1-14.9 years, and 15 years or more) and univariate analyses were performed. RESULTS: Of the 883 pancreatic cancer patients with serologically assessed ABO blood type, 217 (24.6%) had blood type O. Compared with the non-DM group, the DM group had a higher frequency of blood type B [odds ratio (OR) = 2.61, 95%CI: 1.24-5.47; reference group: blood type A]. Moreover, male (OR = 3.17, 95%CI: 1.67-6.06), older than 70 years of age (OR = 2.19, 95%CI: 1.20-3.98) and presence of a family history of diabetes (OR = 6.21, 95%CI: 3.38-11.36) were associated with long-standing type 2 diabetes. The mean ages were 64.8 ± 9.2 years, 67.1 ± 9.8 years, and 71.7 ± 7.0 years in the subgroups with the duration of diabetes, 3-5 years, 5.1-14.9 years, and 15 years or more, respectively (P = 0.007). A comparison of ABO blood type distribution among the subgroups also showed a significant difference (P = 0.03). CONCLUSION: The association of pancreatic cancer with blood type and duration of diabetes needs to be further examined in prospective studies.     

Factors influencing clinical outcomes of Histoacryl~ glue injection-treated gastric variceal hemorrhage

AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl glue injection for acute gastric variceal hemorrhage. METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and posttreatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical outcomes.RESULTS: A total of 90 patients underwent Histoacryl injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR)=10.67, 95%CI: 1.27-89.52, P=0.03 and OR=4.15, 95%CI: 1.34-12.86, P=0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR=4.01, 95%CI: 1.25-12.87, P=0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which were related to infections. The factors s     

Extended antimicrobial prophylaxis after gastric cancer surgery: A systematic review and meta-analysis

AIM: To investigate the efficacy of extended antimicrobial prophylaxis (EAP) after gastrectomy by systematic review of literature and meta-analysis. METHODS: Electronic databases of PubMed, Embase, CINAHL, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register and the China National Knowledge Infrastructure were searched systematically from January 1980 to October 2012. Strict literature retrieval and data extraction were carried out independently by two reviewers and meta-analyses were conducted using RevMan 5.0.2 with statistics tools risk ratios (RRs) and intention-to-treat analyses to evaluate the items of total complications, surgical site infection, incision infection, organ (or space) infection, remote site infection, anastomotic leakage (or dehiscence) and mortality. Fixed model or random model was selected accordingly and forest plot was conducted to display RR. Likewise, Cochrane Risk of Bias Tool was applied to evaluate the quality of randomized controlled trials (RCTs) included in this meta-analysis. RESULTS: A total of 1095 patients with gastric cancer were enrolled in four RCTs. No statistically significant differences were detected between EAP and intraoperative antimicrobial prophylaxis (IAP) in total complications (RR of 0.86, 95%CI: 0.63-1.16, P = 0.32), surgical site infection (RR of 1.97, 95%CI: 0.86-4.48, P = 0.11), incision infection (RR of 4.92, 95%CI: 0.58-41.66, P = 0.14), organ or space infection (RR of 1.55, 95%CI: 0.61-3.89, P = 0.36), anastomotic leakage or dehiscence (RR of 3.85, 95%CI: 0.64-23.17, P = 0.14) and mortality (RR of 1.14, 95%CI: 0.10-13.12; P = 0.92). Likewise, multiple-dose antimicrobial prophylaxis showed no difference compared with single-dose antimicrobial prophylaxis in surgical site infection (RR of 1.10, 95%CI: 0.62-1.93, P = 0.75). Nevertheless, EAP showed a decreased remote site infection rate compared with IAP alone (RR of 0.54, 95%CI: 0.34-0.86, P = 0.01), which is the only significant finding. Unfortunately, EAP did not decrease     

Studies on surgical operations and prognosis of extrahepatic bile duct cancer

AIM: To perform a clinical evaluation of the surgical procedures of extrahepatic bile duct cancer and their influence on prognosis. METHODS: A total of 55 patients with pathologically and clinically verified extrahepatic bile duct cancer treated in our department between January 1984 and December 1993 were analyzed retrospectively. Clinical courses, with respect to the surgical procedures, investigated by follow-up and the survival period was assessed. RESULTS: Among the 55 patients, 24 received surgery that involved the upper third of extrahepatic biliary tract, 12 involving the middle third, and 19 involving the lower third. The diagnosis of bile duct cancer was confirmed histopathologically in 42 of the patients, with a clear predominance of adenocarcinoma (97.6%). Eleven (26.2%) of the patients received curative resection, 30 received palliative procedures (i.e. biliary-enteric bypass (n = 14) and external drainage (n = 16)), 6 received permanent percutaneous transhepatic cholangio-drainage (PTCD) alone, and 8 received exploratory laparotomy only or conservative treatment. Forty-eight patients (87.3%) were followed-up. The overall mean survival period was 10.8 ± 9.7 mo (¯x ± s); patients with curative resection had the longest survival period (21.4 ± 16.7 mo, P < 0.01) and highest survival rate (P < 0.05). A significant survival difference was observed for patients with biliary-enteric anastomosis as compared with those who had external drainage, etc. (P < 0.05), but there was no significant difference in survival period between patients who had preoperative PTCD (n = 23) and those who did not (n = 26) (P < 0.05). CONCLUSION: Curative resection is the treatment of choice for suitable patients with extrahepatic bile duct cancer; biliary-enteric anastomosis is preferable for those with unresectable tumor in order to improve prognosis and quality of life.     

Needle-knife fistulotomy vs double-guidewire technique in patients with repetitive unintentional pancreatic cannulations

AIM: To compare the success rates and adverse events of early needle-knife fistulotomy(NKF) and double-guidewire technique(DGT) in patients with repetitive unintentional pancreatic cannulations.METHODS: From a total of 1650 patients admitted for diagnostic or therapeutic endoscopic retrograde cholangiopancreatography(ERCP) at a single tertiary care hospital(Pusan National University Yangsan Hospital, Yangsan, South Korea) between January2009 and December 2012, 134(8.1%) patients with unsuccessful biliary cannulation after 5 min trial of conventional methods, together with 5 or more repetitive unintentional pancreatic cannulations, were enrolled in the study. Early NKF and DGT groups were assigned 67 patients each. In the DGT group, NKF was performed for an additional 7 min if successful cannulation was not achieved.RESULTS: The success rates with early NKF andthe DGT were 79.1%(53/67) and 44.8%(30/67)(P 0.001), respectively. The incidence of post-ERCP pancreatitis(PEP) was lower in the early NKF group than in the DGT group [4.5%(3/67) vs 14.9%(10/67),P = 0.041]. The mean cannulation times in the early NKF and DGT groups after assignment were 257 s and312 s(P = 0.013), respectively.CONCLUSION: Our data suggest that early NKF should be considered as the first approach to selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.