Endoscopic Papillary Large Balloon Dilation for the Retrieval of Bile Duct Stones After Prior Billroth II Gastrectomy

Background/Aims:

Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.

Materials and Methods:

From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.

Results:

Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.

Conclusions:

EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.     

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/Aims

Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.

Methods

Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.

Results

Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.

Conclusions

Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.     

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth Ⅱ gastrectomy patients

Background: Endoscopic papillary balloon dilation(EPBD) for common bile duct(CBD) stones removal in Billroth Ⅱ gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth Ⅱ gastrectomy patients.Methods: The records of patients with previous Billroth Ⅱ gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography(ERCP) between July 1, 2008 and September 1,2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events,and stone recurrence were analyzed.Results: A total of 83 patients with previous Billroth Ⅱ gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth Ⅱ gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients(85.7%). ERCP-related adverse events was in 3 ERCP procedures(5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients(12.2%) had stone recurrence after a median period of22.5 months(range 6–71 months) from the end of stone removal treatment. Female [odds ratio(OR) = 11.352; 95% confidence interval(95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy(OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.Conclusions: At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth Ⅱ gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.     

Efficacy of Spyglass-Guided Electrohydraulic Lithotripsy in Difficult Bile Duct Stones

Background/Aims:

We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy.

Design:

A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center.

Patients and Methods:

All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL.

Results:

A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis.

Conclusion:

Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones.     

Comparison of Endoscopic Papillary Balloon Dilation and Sphincterotomy in Young Patients with CBD Stones and Gallstones

Background and Aims

Endoscopic biliary sphincterotomy (EBS) results in permanent loss of sphincter function and its long-term complications are unknown. Endoscopic papillary balloon dilation (EPBD) is an alternative procedure that preserves sphincter function, although it is associated with a higher risk of pancreatitis than is EBS. The aim of this study was to evaluate the safety and outcomes of EPBD with limited indications for removal of common bile duct (CBD) stones combined with gallstones in patients younger than 40 years.

Methods

Young (age < 40 years) patients who had CBD stones combined with gallstones on imaging studies were enrolled in this study. A total of 132 patients were randomly divided into the EPBD group (n = 62) or the EBS group (n = 70) for extraction of CBD stones. The ballooning size of EPBD ranged from 6 to 10 mm.

Results

Complete bile duct clearance was achieved in 98.4 % (61/62) of the EPBD group and 100 % (70/70) of the EBS group. Mechanical lithotripsy was required in 8.1 % (5/62) of the EPBD group and 8.6 % (6/70) of the EBS group. The early complication rates were 8.1 % (5/62) (five pancreatitis) in the EPBD group and 11.4 % (8/70) (five [7.1 %] pancreatitis, two bleeding and one perforation) in the EBS group. The recurrence rates of CBD stones were 1.6 % (1/62) in the EPBD group and 5.7 % (4/70) in the EBS group.

Conclusions

EPBD with limited indications was safe and effective as EBS for removal of CBD stones combined with gallstones in young patients who had a longer life expectancy.     

Investigation of predictors of increased creatine kinase levels following vascular surgery and the association with peri-operative statin therapy

Summary

Although peri-operative statin administration is likely to be cardioprotective, there remains a concern about the risk of rhabdomyolysis and associated renal failure following statin administration in the peri-operative period. The aim of this study was to determine independent predictors of creatine kinase (CK) elevation following vascular surgery.

Design

A retrospective cohort study was conducted. A multivariate analysis using binary logistic regression was conducted of clinical, surgical and laboratory factors which may be associated with a CK exceeding five times the upper limit of normal (ULN).

Results

Four independent predictors associated with a CK > 5 ULN were identified. Statin therapy was protective [odds ratio (OR) 0.096, 95% confidence interval (CI) 0.014–0.68, p = 0.019], and a serum creatinine > 180 μmol.l^-1, positive serum troponins and embolectomy and/or fasciotomy were associated with CK elevation (OR 3.32, 95% CI: 1.03–10.7, p = 0.04; OR 5.84, 95% CI: 1.52–22.4, p = 0.01; OR 5.62, 95% CI: 1.14–27.8, p = 0.03 respectively). Statin therapy was associated with decreased mortality (OR 0.26, 95% CI: 0.08–0.86, p = 0.028).

Conclusion

It may be preferable to continue statin therapy in vascular surgical patients even when CK is elevated, as this may decrease mortality if the CK elevation is in the presence of pre-existing renal dysfunction, peri-operative cardiac events or following embolectomy or fasciotomy. Further investigation is required to confirm this observation.     

Validation of a model to predict all-cause in-hospital mortality in vascular surgical patients

Objective

To develop and validate a pre- and postoperative model of all-cause in-hospital mortality in South African vascular surgical patients.

Methods

We carried out a retrospective cohort study. A multivariate analysis using binary logistic regression was conducted on a derivation cohort using clinical, physiological and surgical data. Interaction and colinearity between covariates were investigated. The models were validated using the Homer-Lemeshow goodness-of-fit test.

Results

Independent predictors of in-hospital mortality in the pre-operative model were: (1) age (per one-year increase) [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.0–1.06), (2) creatinine > 180 μmol.l^-1 (OR 6.43, 95% CI: 3.482–11.86), (3) chronic beta-blocker therapy (OR 2.48, 95% CI: 1.38–4.48), and (4) absence of chronic statin therapy (OR 2.81, 95% CI: 1.15–6.83). Independent predictors of mortality in the postoperative model were: (1) age (per oneyear increase) (OR 1.05, 95% CI: 1.02–1.09), (2) creatinine > 180 μmol.l^-1 (OR 5.08, 95% CI: 2.50–10.31), (3) surgery out of hours without statin therapy (OR 8.27, 95% CI: 3.36–20.38), (4) mean daily postoperative heart rate (HR) (OR 1.02, 95% CI: 1.0–1.04), (5) mean daily postoperative HR in the presence of a mean daily systolic blood pressure of less than 100 beats per minute or above 179 mmHg (OR 1.02, 95% CI: 1.01–1.03) and (6) mean daily postoperative HR associated with withdrawal of chronic beta-blockade (OR 1.02, 95% CI: 1.01–1.03). Both models were validated.

Conclusion

The pre-operative model may predict the risk of in-hospital mortality associated with vascular surgery. The postoperative model may identify patients whose risk increases as a result of surgical or physiological factors.     

Efficacy and safety of sirolimus-eluting stents versus bare-metal stents in coronary artery disease patients with diabetes: a meta-analysis

Objective

To compare by meta-analysis the efficacy and safety of sirolimus-eluting and bare-metal stents in coronary artery disease (CAD) patients with diabetes.

Methods

PubMed, MEDLINE and EMBASE were searched from 1971 to 2012. Data on the efficacy and safety of sirolimus-eluting and bare-metal stents in patients with diabetes were collected. A meta-analysis was then performed on a total of 1 259 CAD patients with diabetes from six studies. The odds ratio (OR) was used for comparison. Subgroup analysis was performed according to the sample size, year of study, subjects’ geographic area and study method.

Results

Compared with those in the bare-metal stent group (BMS), the subjects in the sirolimus-eluting stent (SES) group had a reduced risk for major cardiac events [OR 0.42, 95% confidence interval (CI): 024–0.74, p < 0.01] and target-lesion revascularisation (OR 0.26, 95% CI: 0.11–0.59, p < 0.01). There was no difference for myocardial infarction (OR 0.92, 95% CI: 0.61–1.40, p > 0.05) or mortality (OR 1.19, 95% CI: 0.74–1.92, p > 0.05). Subgroup analysis showed a significant difference for overall risk of major cardiac events between SES and BMS when the sample size was ≤ 90 (OR 0.28, 95% CI: 0.16–0.48, p < 0.01), when it was a randomised control trial (RCT) (OR 0.28, 95% CI: 0.19–0.42, p < 0.01), or when it was performed on European subjects (OR 0.45, 95% CI: 0.27–0.77, p < 0.01). The sensitivity was not different when one study was removed at a time.

Conclusion

Our study confirmed that SES are safer and more effective than BMS in CAD patients with diabetes, as far as major cardiac events are concerned.     

The 12-lead ECG in peripartum cardiomyopathy

Background

The value of the 12-lead electrocardiogram (ECG) to provide prognostic information in the deadly and disabling syndrome peripartum cardiomyopathy (PPCM) is unknown.

Aims

To determine the prevalence of major and minor ECG abnormalities in PPCM patients at the time of diagnosis, and to establish whether there are ECG correlates of persistent left ventricular dysfunction and/or clinical stability at six months of follow up, where available.

Methods

Twelve-lead ECGs were performed at the point of diagnosis on 78 consecutive women presenting with PPCM to two tertiary centres in South Africa and 44 cases (56%) at the six-month follow up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes.

Results

The cohort mainly comprised young women of black African ancestry (90%) [mean age 29 ± 7 years and median body mass index 24.3 (IQR: 22.7–27.5) kg/m²]. The majority of cases (n = 70; 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor changes were detected in 49% (95% CI: 37–60%) and 62% (95% CI: 51–74%) of cases, respectively; the most common being T-wave changes (59%), p-wave abnormality (29%) and QRS-axis deviation (25%).Of the 44 cases (56%) reviewed at six months, normalisation of the 12-lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats/min; p < 0.001) and abnormal QRS axis (36 vs 14%; p = 0.014). On an adjusted basis, major T-wave abnormalities on the baseline 12-lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of –9%, 95% CI: –1 to –16; p = 0.03) and at six months (–12%; 95% CI: –4 to –24; p = 0.006). Similarly, baseline ST-segment elevation was also associated with lower LVEF at six months (–25%; 95% CI: –0.7 to –50; p = 0.04).

Conclusions

In this unique study, we found that almost all women suffering from PPCM had an ‘abnormal’ 12-lead ECG. Pending more definitive studies, the ECG appears to be a useful adjunctive tool in both screening and prognostication in resource-poor settings.     

Corticosteroid therapy for primary treatment of Kawasaki disease – weight of evidence: a meta-analysis and systematic review of the literature

Objective

Corticosteroids are the treatment of choice in most forms of vasculitis. However, their role in the primary treatment of Kawasaki disease (KD) is controversial. Our aim was to conduct a meta-analysis to assess the clinical course and coronary artery outcome of adding corticosteroids to standard therapy [intravenous immunoglobulin (IVIG) + aspirin] in patients with acute KD.

Methods

We included randomised trials comparing the addition of corticosteroids to conventional primary therapy for Kawasaki disease.

Results

A total of four studies were identified, which included 447 patients. The meta-analysis revealed a significant reduction in re-treatments with IVIG in patients receiving corticosteroid plus standard therapy compared with standard therapy alone [odds ratio (OR) 0.48; 95% confidence interval (CI): 0.24– 0.95]. There was however no significant reduction in the incidence of coronary artery aneurysms among patients who received corticosteroid therapy plus standard therapy, compared with standard therapy alone for either up to a month (OR 0.74; 95% CI: 0.23–2.40) or over one month ([OR 0.74; 95% CI: 0.37–1.51). Similarly no significant differences between treatment groups were noted in incidence of adverse events (OR 0.81; 95% CI: 0.05–0.88).

Conclusion

The inclusion of corticosteroids in regimens for the initial treatment of Kawasaki disease decreased rates of re-treatment with intravenous immunoglobulin. However the addition of corticosteroids to standard therapy did not decrease the incidence of coronary aneurysms or adverse events.     

Liver resection after chemotherapy and tumour downsizing in patients with initially unresectable colorectal cancer liver metastases

Objectives

Among patients with initially unresectable colorectal cancer liver metastases (CLM), a subset are rendered resectable following the administration of systemic chemotherapy. This study reports the results achieved in liver resections performed at a single hepatobiliary referral centre after downsizing chemotherapy in patients with initially unresectable CLM.

Methods

All liver resections for CLM performed over a 10-year period at the Toronto General Hospital were considered. Data on initially non-resectable patients who received systemic therapy and later underwent surgery were included for analysis.

Results

Between January 2002 and July 2012, 754 liver resections for CLM were performed. A total of 24 patients were found to meet the study inclusion criteria. Bilobar CLM were present in 23 of these 24 patients. The median number of tumours was seven (range: 2–15) and median tumour size was 7.0 cm (range: 1.0–12.8 cm) before systemic therapy. All patients received oxaliplatin-or irinotecan-based chemotherapy. Fourteen patients received combined treatment with bevacizumab. Negative margin (R0) resection was accomplished in 21 of 24 patients. There was no perioperative mortality. Ten patients suffered perioperative morbidity. Eighteen patients suffered recurrence of disease within 9 months. Rates of disease-free survival at 1, 2 and 3 years were 47.6% [95% confidence interval (CI) 30.4–74.6%], 23.8% (95% CI 11.1–51.2%) and 19.0% (95% CI 7.9–46.0%), respectively. Overall survival at 1, 2 and 3 years was 91.5% (95% CI 80.8–100%), 65.3% (95% CI 48.5–88.0%) and 55.2% (95% CI 37.7–80.7%), respectively.

Conclusions

Liver resection in initially unresectable CLM can be performed with low rates of morbidity and mortality in patients who respond to systemic chemotherapy, although these patients do experience a high frequency of disease recurrence.     

In-hospital mortality after resection of biliary tract cancer in the United States

Objective:

To assess perioperative mortality following resection of biliary tract cancer within the U.S.

Background:

Resection remains the only curative treatment for biliary tract cancer. However, current data on operative mortality after surgical resections for biliary tract cancer are limited to small and single-center studies.

Methods:

Using the Nationwide Inpatient Sample 1998–2006, a cohort of patient-discharges was assembled with a diagnosis of biliary tract cancer, including intrahepatic bile duct, extrahepatic bile duct, and gall bladder cancers. Patients undergoing resection, including hepatic resection, bile duct resection, pancreaticoduodenectomy, and cholecystectomy, were retained. The primary outcome measure was in-hospital mortality. Categorical variables were analyzed by chi-square. Multivariable logistic regression was performed to identify independent predictors of in-hospital mortality following resection.

Results:

31 870 patient-discharges occurred for the diagnosis of biliary tract cancer, including 36.2% intrahepatic ductal, 26.7% extrahepatic ductal, and 31.1% gall bladder. Of the total, 18.6% underwent resection: mean age was 69.3 years (median 70.0); 60.8% were female; 73.7% were white. Overall inpatient surgical mortality was 5.6%. Independently predictive factors of mortality included patient age ≥50 (vs. <50; age 50–59 odds ratio [OR] 5.51, 95% confidence interval [CI] 1.70–17.93; age 60–69 OR 7.25, 95% CI 2.29–22.96; age ≥ 70 OR 9.03, 95% CI 2.86–28.56), the presence of identified comorbidities (congestive heart failure, OR 3.67, 95% CI 2.61–5.16; renal failure, OR 4.72, 95% CI 2.97–7.49), and admission designated as emergent (vs. elective; OR 1.82, 95% CI 1.39–2.37).

Conclusion:

Increased in-hospital mortality for patients undergoing biliary tract cancer resection corresponded to age, comorbidity, hospital volume, and emergent admission. Further study is warranted to utilize these observations in promoting early detection, diagnosis, and elective resection.     

Alpha-fetoprotein and tumour size are associated with microvascular invasion in explanted livers of patients undergoing transplantation with hepatocellular carcinoma

Background:

To determine factors associated with outcomes and microvascular invasion (MVI) in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC).

Methods:

Between July 1996 and August 2008 at the Universities of Kentucky or Tennessee, LT recipients were retrospectively analysed.

Results:

One hundred and one patients had HCC in the explanted liver; one patient was excluded because of fibrolamellar histology. Seventy-nine (79%) were male and 81 (81%) were older than 50. HCC was incidental in 32 patients (32%). Median follow-up was 31 months. Ten patients (10%) developed recurrence, which was associated with poor survival (P= 0.006). Overall 1-, 3-, and 5-year survival rates were 87%, 69% and 62%, respectively. Excluding patients with lymph node metastasis (LNM) or MVI yielded 91%, 81% and 75% survival at the same time points. MVI was independently associated with recurrence (OR 28.40, 95% CI 1.77–456.48, P= 0.018) and decreased survival (OR 4.70, 95% CI 1.24–17.80, P= 0.023), and LNM with decreased survival (OR 6.05, 95% CI 1.23–29.71, P= 0.027). Tumour size (OR 4.1, 95% CI 1.2–13.5, P= 0.013) and alpha-fetoproptein (AFP) > 100 (OR 5.0, 95% CI 1.4–18.1, P= 0.006) were associated with MVI.

Conclusions:

MVI greatly increases the risk of recurrence and death after LT for HCC, and is strongly associated with tumour size and AFP > 100.     

Epidemiological impact of mandatory vaccination against hepatitis B in Italian young adults

Background

Viral hepatitis caused by hepatitis B virus (HBV) is a leading cause of acute and chronic liver diseases worldwide.

Objectives

In Italy, a mandatory vaccination policy was introduced in 1991 and was established for all newborns and 12-year-old individuals. In 2004, vaccination of 12-yearold adolescents was discontinued, and that of infants was maintained.

Patients and Methods

We evaluated the seroprevalence of HBV markers in 806 individuals, who were vaccinated at birth or at 12 years of age, to assess the effectiveness of the national policy against HBV.

Results

The overall prevalence of anti-HBs antibodies was 90.32% (95% confidence interval [CI]: 88.28–92.36%); 2.23% (95% CI: 1.21–3.25%) of the subjects were positive for both antibodies to HBsAg (anti-HBs) and antibodies to hepatitis B core antigen (anti-HBc), whereas 5.83% (95% CI 4.21–7.45) of the subjects were negative for all markers tested. Further, 1.61% (95% CI: 0.74–2.48%) of the subjects were positive for hepatitis B surface antigen (HBsAg).

Conclusions

Our data provide additional evidence that HBV vaccination can confer long-term immunity when performed at birth and when performed for healthy adolescents; moreover, the results show the effectiveness of the application of a national vaccination strategy.     

Control Beliefs and Risk for Death,Stroke and Myocardial Infarction in Middle-aged and Older Adults: An Observational Study

Background

Chronic health conditions account for the largest proportion of illness-related mortality and morbidity as well as most of healthcare spending in the USA. Control beliefs may be important for outcomes in individuals with chronic illness.

Objective

To determine whether control beliefs are associated with the risk for death, incident stroke and incident myocardial infarction (MI), particularly for individuals with diabetes mellitus (DM) and/or hypertension.

Design

Retrospective cohort study.

Participants

A total of 5,662 respondents to the Health and Retirement Study with baseline health, demographic and psychological data in 2006, with no history of previous stroke or MI.

Main Measures

Perceived global control, measured as two dimensions—“constraints” and “mastery”—and health-specific control were self-reported. Event-free survival was measured in years, where “event” was the composite of death, incident stroke and MI. Year of stroke or MI was self-reported; year of death was obtained from respondents’ family.

Key Results

Mean baseline age was 66.2 years; 994 (16.7 %) had DM and 3,023 (53.4 %) hypertension. Overall, 173 (3.1 %) suffered incident strokes, 129 (2.3 %) had incident MI, and 465 (8.2 %) died. There were no significant interactions between control beliefs and baseline DM or hypertension in predicting event-free survival. Elevated adjusted hazard ratios (HRs) were associated with DM (1.33, 95 % CI 1.07–1.67), hypertension (1.31, 95 % CI 1.07–1.61) and perceived constraints in the third (1.55, 95 % CI 1.12–2.15) and fourth quartiles (1.61, 95 % CI 1.14–2.26). Health-specific control scores in the third (HR 0.78, 95 % CI 0.59–1.03) and fourth quartiles (HR 0.70, 95 % CI 0.53–0.92) were protective, but only the latter category had a statistically significant decreased risk. Combined high perceived constraints and low health-specific control had the highest risk (HR 1.93, 95 % CI 1.41–2.64).

Conclusions

Control beliefs were not associated with differential risk for those with DM and/or hypertension, but they predicted significant differences in event-free survival for the general cohort.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3275-9) contains supplementary material, which is available to authorized users.KEY WORDS: control beliefs, mortality, cardiovascular risk     

Meta-analysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: a Cochrane review

Background:

The use of synthetic analogues of somatostatin following pancreatic surgery is controversial. The aim of this meta-analysis is to determine whether prophylactic somatostatin analogues (SAs) should be used routinely in pancreatic surgery.

Methods:

Randomized controlled trials were identified from the Cochrane Library Trials Register, MEDLINE, EMBASE, Science Citation Index Expanded and reference lists. Data were extracted from these trials by two independent reviewers. The risk ratio (RR), mean difference (MD) and standardized mean difference (SMD) were calculated with 95% confidence intervals (95% CIs) based on intention-to-treat or available case analysis.

Results:

Seventeen trials involving 2143 patients were identified. The overall number of patients with postoperative complications was lower in the SA group (RR 0.71, 95% CI 0.62–0.82), but there was no difference between the groups in perioperative mortality (RR 1.04, 95% CI 0.68–1.59), re-operation rate (RR 1.15, 95% CI 0.56–2.36) or hospital stay (MD −1.04 days, 95% CI −2.54 to 0.46). The incidence of pancreatic fistula was lower in the SA group (RR 0.64, 95% CI 0.53–0.78). The proportion of these fistulas that were clinically significant is not clear. Analysis of results of trials that clearly distinguished clinically significant fistulas revealed no difference between the two groups (RR 0.69, 95% CI 0.34–1.41). Subgroup analysis revealed a shorter hospital stay in the SA group than among controls for patients with malignant aetiology (MD −7.57 days, 95% CI −11.29 to −3.84).

Conclusions:

Somatostatin analogues reduce perioperative complications but do not reduce perioperative mortality. However, they do shorten hospital stay in patients undergoing pancreatic surgery for malignancy. Further adequately powered trials of low risk of bias are necessary.     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

Elevated salivary C-reactive protein predicted by low cardio-respiratory fitness and being overweight in African children

Introduction

C-reactive protein (CRP) is a sensitive marker of systemic inflammation and is an independent risk factor for cardiovascular disease. The aim of the study was to examine the relationship between salivary CRP, cardio-respiratory fitness and body composition in a paediatric population.

Methods

This was a cross-sectional study of 170 black South African children (age 9.41 ± 1.55 years, 100 females, 70 males) in grades 3 to 7. Unstimulated whole saliva samples were obtained for the analysis of CRP. Height, mass, skin-fold thickness, resting blood pressure, and waist and hip circumference measurements were obtained. Cardio-respiratory fitness was assessed using a 20-m multi-stage shuttle run. Children were classified as overweight/obese according to the Center for Disease Control and Prevention (CDC) body mass index (BMI) percentile ranking, and meeting percentage body fat recommendations, if percentage body fat was ≤ 25% in boys and ≤ 32% in girls. The cut-off point for low cardio-respiratory fitness was a predicted aerobic capacity value ≤ the 50th percentile for the group. Contributions of low cardio-respiratory fitness, overweight/obesity, and not meeting percentage body fat recommendations, to elevated salivary CRP (≥ 75th percentile) concentration and secretion rate were examined using binary logistic regression analysis with a backward stepwise selection technique based on likelihood ratios.

Results

Poor cardio-respiratory fitness was independently associated with elevated salivary CRP concentration (OR 3.9, 95% CI: 1.7–8.9, p = 0.001). Poor cardio-respiratory fitness (OR 2.7, 95% CI: 1.2–6.1, p = 0.02) and overweight/obesity (BMI ≥ 85th percentile) (OR 2.5, 95% CI: 1.1–5.9, p = 0.03) were independent predictors of elevated salivary CRP secretion rate.

Conclusion

The results suggest a strong association between poor cardio-respiratory fitness and/or overweight/obesity and inflammatory status in children, based on elevated salivary CRP levels.     

Role of D-dimer in the Development of Portal Vein Thrombosis in Liver Cirrhosis: A Meta-analysis

Background and Aims:

A meta-analysis was performed to explore the role of the D-dimer in the development of portal vein thrombosis (PVT) in liver cirrhosis.

Methods:

All papers were searched via PubMed, EMBASE, China National Knowledge Infrastructure, Wan Fang, and VIP databases. A standardized mean difference (SMD) with 95% confidence interval (CI) was pooled.

Results:

Overall, 284 studies were initially identified, of which 21 were included. Cirrhotic patients with PVT had a significantly higher D-dimer concentration than those without PVT (pooled SMD = 1.249, 95%CI = 0.740–1.758). After the portal hypertension-related surgery, cirrhotic patients with PVT had a similar preoperative D-dimer concentration to those without PVT (pooled SMD = 0.820, 95%CI = −0.122–0.286), but a higher postoperative value of D-dimer concentration than those without PVT (pooled SMD = 2.505, 95%CI = 0.975–4.036). Notably, the D-dimer concentration at the 1^st postoperative day was similar between cirrhotic patients with and without PVT (pooled SMD = 0.137, 95%CI = −0.827–1.101), but that at the 7^th post-operative day was higher in cirrhotic patients with PVT than in those without PVT (pooled SMD = 1.224, 95%CI = 0.277–2.171).

Conclusion:

D-dimer might be regarded as a diagnostic marker for PVT in liver cirrhosis. In addition, postoperative D-dimer testing is worthwhile for the diagnosis of PVT after portal hypertension-related surgery.