Si-Jia Wu

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones.

AIM To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones. METHODS Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores. RESULTS Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management. CONCLUSION Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patients condition, operators expertise and local resources should be taken into account in making treatment decisions.

Single-incision laparoscopic appendectomy vs conventional laparoscopic appendectomy: Systematic review and meta-analysis

AIM To assess the differences in clinical benefits and disadvantages of single-incision laparoscopic appendectomy (SILA) and conventional laparoscopic appendectomy (CLA). METHODS The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database were electronically searched up through January 2013 to identify randomized controlled trails (RCTs) comparing SILA with CLA. Data was extracted from eligible studies to evaluate the pooled outcome effects for the total of 1068 patients. The meta-analysis was performed using Review Manager 5.2.0. For dichotomous data and continuous data, the risk ratio (RR) and the mean difference (MD) were calculated, respectively, with 95%CI for both. For continuous outcomes with different measurement scales in different RCTs, the standardized mean difference (SMD) was calculated with 95%CI. Sensitivity and subgroup analyses were performed when necessary. RESULTS Six RCTs were identified that compared SILA (n = 535) with CLA (n = 533). Five RCTs had a high risk of bias and one RCT had a low risk of bias. SILA was associated with longer operative time (MD = 5.68, 95%CI: 3.91-7.46, P < 0.00001), higher conversion rate (RR = 5.14, 95%CI: 1.25-21.10, P = 0.03) and better cosmetic satisfaction score (MD = 0.52, 95%CI: 0.30-0.73, P < 0.00001) compared with CLA. No significant differences were found for total complications (RR = 1.15, 95%CI: 0.76-1.75, P = 0.51), drain insertion (RR = 0.72, 95%CI: 0.41-1.25, P = 0.24), or length of hospital stay (SMD = 0.04, 95%CI: -0.08-0.16, P = 0.57). Because there was not enough data among the analyzed RCTs, postoperative pain was not calculated. CONCLUSION The benefit of SILA is cosmetic satisfaction, while the disadvantages of SILA are longer operative time and higher conversion rate.

Laparoscopic vs. open cholecystectomy for cirrhotic patients: a systematic review and meta-analysis.

BACKGROUND/AIMS To compare the safety and effectiveness of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) for cirrhotic patients. METHODOLOGY The Cochrane Library, MEDLINE, Science Citation Index Expanded, EMBASE and CBM (Chinese Biomedical Database) were searched until August 2011 to indentify relevant and eligible studies. RESULTS Twenty three articles with 1316 cirrhotic patients were included. All patients were allocated to the LC group (n=694) or the OC group (n=622). They were primarily in Child-Pugh class A (n=957, 72.7%) and class B (n=343, 26.1%). Meta-analysis of 5 randomized controlled trials (n=284) indicated LC group was associated with the following advantages: significant lower surgery-related morbidity, less postoperative complications (e.g. incision hernia, wound infection), shorter hospital stay and less loss of blood. There were no significant differences in the intra-hospital mortality and total operative time between the two groups. Meta-analysis of 19 non-randomized studies (n=1082) showed similar results in favour of LC group. In addition, it showed significant lower intra-hospital mortality and less total operative time in the LC group than the OC group. CONCLUSIONS LC is safe and offers various significant benefits over OC. Thus, it should be recommended for compensated cirrhotic patients.

Lymphocyte to monocyte ratio and prognostic nutritional index predict survival outcomes of hepatitis B virus-associated hepatocellular carcinoma patients after curative hepatectomy.

Lymphocytes are an integral part of lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI). Both LMR and PNI which reflect bodys inflammatory and nutritional status can be obtained from routine blood and biochemical test conveniently. Little evidence concerning the prognostic value of LMR and PNI in hepatocellular carcinoma (HCC) patients has been published. This study aimed to investigate the prognostic value of LMR and PNI in hepatitis B virals (HBV)—associated HCC patients who underwent curative hepatectomy.

Comparison of the efficacy of ondansetron and granisetron to prevent postoperative nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis.

Background/Aims: Our purpose was to assess the prophylactic antiemetic effects of ondansetron versus granisetron for laparoscopic cholecystectomy. Methods: We searched Medline, Cochrane Central Register of Controlled Trials, PubMed, Embase, Science Citation Index Expanded, Foreign Medical Journal Full-Text Service, China National Knowledge Infrastructure Whole Article Database, Chinese Biomedical Database, and the Google Scholar. We calculated the risk ratio (RR) with 95% confidence interval (CI) for dichotomous data. The &khgr;2 test and I2 value were used to assess heterogeneity. Results: The merged early incidence of postoperative nausea and vomiting (PONV) in ondansetron group (42.9%) was higher than granisetron group (34.3%) (RR=1.25, 95% CI, 0.82-1.92, P=0.31, I2=48%). The merged total incidence of PONV in ondansetron group (38.7%) was higher than granisetron group (34.2%) (RR=1.13, 95% CI, 0.82-1.56, P=0.46, I2=39%), although these differences were not statistically significant. Conclusions: Ondansetron is equivalent to granisetron for preventing early and total incidence of PONV after laparoscopic cholecystectomy.

Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection

BACKGROUND Alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) are routinely tested before surgery and are easily obtained. They are also the most widely used tumor markers, which have a certain reference value in the diagnosis of hepatocellular carcinoma (HCC). The prognostic values of ALP, GGT and LDH have not been explored deeply and few studies have investigated the prognosis value of them in surgically treated HCC patients. Our study was performed to verify the prognostic significance of preoperative ALP, GGT and LDH in hepatitis B virus (HBV)-related HCC patients receiving curative hepatectomy. MATERIALS AND METHODS 469 pathologically confirmed HCC patients who received curative hepatectomy were retrospectively analyzed. Significant clinicopathological factors were collected and analyzed. Independent prognostic factors were identified by the multivariate analysis. Overall survival (OS) and recurrence-free survival (RFS) curves were analyzed and compared between different groups. RESULTS Patients with low level of ALP, GGT and LDH have favorable OS and RFS, even in cirrhosis subgroup. ALP, GGT and LDH were also closely related to some important clinicopathological parameters. GGT and LDH were significant independent prognostic factors of both OS and RFS, while ALP was just a significant independent prognostic factor of OS, rather than RFS. CONCLUSIONS Preoperative ALP, GGT and LDH could predict prognosis in HBV-related HCC patients who received curative liver resection.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography: A meta-analysis and systematic review

AIM To assess the safety and efficacy of carbon dioxide (CO(2)) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO(2) insufflation with air insufflation during ERCP. The trials were included in the review irrespective of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes. Sensitivity and subgroup analyses were performed if necessary. RESULTS Seven double-blind RCTs involving a total of 818 patients were identified that compared CO(2) insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-randomization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO(2) insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insufflation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI: 0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO(2) level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI: -14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI: -0.26-0.17, P = 0.67) between the two groups. CONCLUSION CO(2) insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

Fast-Track Programs for Liver Surgery: A Meta-Analysis

Background and ObjectivesPlentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery.MethodsThe following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings.ResultsAltogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies.ConclusionsFast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.

Prognostic value of lymphovascular invasion in Bismuth-Corlette type IV hilar cholangiocarcinoma

AIM To assess the prognostic value of lymphovascular invasion (LVI) in Bismuth-Corlette type IV hilar cholangiocarcinoma (HC) patients. METHODS A retrospective analysis was performed on 142 consecutively recruited type IV HC patients undergoing radical resection with at least 5 years of follow-up. Survival analysis was performed by the Kaplan-Meier method, and the association between the clinicopathologic variables and survival was evaluated by log-rank test. Multivariate analysis was adopted to identify the independent prognostic factors for overall survival (OS) and disease-free survival (DFS). Multiple logistic regression analysis was performed to determine the association between LVI and potential variables. RESULTS LVI was confirmed histopathologically in 29 (20.4%) patients. Multivariate analysis showed that positive resection margin (HR = 6.255, 95%CI: 3.485-11.229, P < 0.001), N1 stage (HR = 2.902, 95%CI: 1.132-7.439, P = 0.027), tumor size > 30 mm (HR = 1.942, 95%CI: 1.176-3.209, P = 0.010) and LVI positivity (HR = 2.799, 95%CI: 1.588-4.935, P < 0.001) were adverse prognostic factors for DFS. The independent risk factors for OS were positive resection margin (HR = 6.776, 95%CI: 3.988-11.479, P < 0.001), N1 stage (HR = 2.827, 95%CI: 1.243-6.429, P = 0.013), tumor size > 30 mm (HR = 1.739, 95%CI: 1.101-2.745, P = 0.018) and LVI positivity (HR = 2.908, 95%CI: 1.712-4.938, P < 0.001). LVI was associated with N1 stage and tumor size > 30 mm. Multiple logistic regression analysis indicated that N1 stage (HR = 3.312, 95%CI: 1.338-8.198, P = 0.026) and tumor size > 30 mm (HR = 3.258, 95%CI: 1.288-8.236, P = 0.013) were associated with LVI. CONCLUSION LVI is associated with N1 stage and tumor size > 30 mm and adversely influences DFS and OS in type IV HC patients.

Elevated red blood cell distribution width predicts poor prognosis in hilar cholangiocarcinoma

Background Although the red blood cell distribution width (RDW) has been reported as a reliable predictor of prognosis in several types of cancer, the prognostic value of RDW in hilar cholangiocarcinoma (HC) has not been studied. Methods A retrospective analysis of 292 consecutively recruited HC patients undergoing radical resection was conducted. The optimal cutoff value of RDW was determined by the receiver operating characteristic curve (ROC). Survival analysis by the Kaplan-Meier method, the difference between the clinico-pathologic variables and survival were evaluated by log-rank analysis. Multivariate analysis identified independent prognostic risk factors of overall survival (OS). Results ROC analysis suggested that the optimal cutoff value for the RDW was 14.95. Linear correlation analysis revealed that RDW is associated with white blood cell count (P = 0.007), neutrophil-to-lymphocyte ratio (P = 0.02), and hemoglobin (P < 0.001), albumin (P < 0.001). In a multivariate analysis, the RDW was an independent prognostic factor for OS (HR = 1.755, 95% CI 1.311-2.349, P < 0.001). Conclusions Elevated RDW may be regarded as an indicator of systemic inflammatory response which might facilitate HC growth and metastasis. Current evidence suggests that RDW may have clinical significance in predicting OS after surgery in HC patients.