Srinivas R. Puli

EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review.

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (Nxa0=xa0283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (Nxa0=xa0376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CIxa0=xa074.47–85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CIxa0=xa054.51–64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

BACKGROUNDnAcute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results.nnnOBJECTIVEnWe conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis.nnnDESIGNnMEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency.nnnSETTINGnSystematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis.nnnPATIENTSnAdult patients undergoing ERCP.nnnINTERVENTIONSnPancreatic stent placement for the prevention of post-ERCP pancreatitis.nnnMAIN OUTCOME MEASUREMENTSnPost-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement.nnnRESULTSnEight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies.nnnLIMITATIONSnSmall sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement.nnnCONCLUSIONSnPancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review.

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (Nxa0=xa05,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3–90.0%] and 98.3% (95% CI 97.8–98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9–82.9%) and 95.6% (95% CI 94.9–96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4–97.2%) and 90.6% (95% CI 89.5–91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4–97.5%) and specificity of 98.3% (95% CI 97.8–98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates wasxa0>xa00.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Accuracy of Endoscopic Ultrasound to Diagnose Nodal Invasion by Rectal Cancers: A Meta-Analysis and Systematic Review

BackgroundNodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent.AimTo evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers.MethodStudy Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL. Statistical Method: Pooling was conducted by both fixed-effects model and random-effects model.ResultsThe initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (Nxa0=xa02732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6–75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5–78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16–3.72), and negative likelihood ratio was 0.42 (95% CI 0.33–0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10.ConclusionsEUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials

Purpose Music has been utilized as a therapeutic tool during colonoscopy, but various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. Patients and Methods Multiple medical databases were searched (12/06). Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Meta-analysis was analyzed for total procedure time, dose of sedative medications (midazolam and mepiridine), and patients’ pain scores, experience, and willingness to repeat the same procedure in the future. Results Eight studies (Nxa0=xa0712) met the inclusion criteria. Patients’ overall experience scores (Pxa0<xa00.01) were significantly improved with music. No significant differences were noted for patients’ pain scores (Pxa0=xa00.09), mean doses of midazolam (Pxa0=xa00.10), mean doses of meperidine (Pxa0=xa00.23), procedure times (Pxa0=xa00.06), and willingness to repeat the same procedure in future (Pxa0=xa00.10). Conclusions Music improves patients’ overall experience with colonoscopy.

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis

BackgroundThe role of prophylactic antibiotics in laparoscopic cholecystectomy in low-risk patients is controversial. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low-risk patients (those without cholelithiasis or cholangitis) undergoing laparoscopic cholecystectomy.MethodsMultiple databases and abstracts were searched. Randomized controlled trials (RCTs) comparing prophylactic antibiotics to placebo or no antibiotics in low-risk laparoscopic cholecystectomy were included. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of overall infections, superficial wound infections, major infections, distant infections, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio or weighted mean difference. Both random and fixed effects models were used. Publication bias was assessed by funnel plot. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.ResultsNine RCTs (Nu2009=u20091,437) met the inclusion criteria. No statistically significant reduction was noted for those receiving prophylactic antibiotics and those who did not for overall infectious complications (pu2009=u20090.20), superficial wound infections (pu2009=u20090.36), major infections (pu2009=u20090.97), distant infections (pu2009=u20090.28), or length of hospital stay (pu2009=u20090.77). No statistically significant publication bias or heterogeneity were noted.ConclusionsProphylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy.

Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: A systematic review and meta analysis

AIMnTo detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs.nnnMETHODSnOnly EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model).nnnRESULTSnInitial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendalls tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10.nnnCONCLUSIONnEUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.

Can Endoscopic Ultrasound Predict Early Rectal Cancers That Can Be Resected Endoscopically? A Meta-Analysis and Systematic Review

BackgroundRectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied.AimTo evaluate the accuracy of EUS in T0 staging of rectal cancers.Method (Study Selection Criteria)Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa.Data Collection and ExtractionArticles were searched in Medline, PubMed, and CENTRAL.Statistical MethodPooling was conducted by both the fixed-effects model and random-effects model.ResultsAn initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (Nxa0=xa01,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7–99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3–97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3–29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04–0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10.ConclusionsEUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis

BACKGROUND:u2003Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (≤4 h) after PEG placement.METHODS:u2003Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (≤4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death ≤72 h, and significant increases in postprocedural gastric residual volume during day 1.RESULTS:u2003Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (≤4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47–1.58, P = 0.63) or death in ≤72 h (OR 0.56, 95% CI 0.18–1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02–3.19, P = 0.04).CONCLUSIONS:u2003Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.

Successful Complete Cure En-Bloc Resection of Large Nonpedunculated Colonic Polyps by Endoscopic Submucosal Dissection: A Meta-Analysis and Systematic Review

BackgroundEndoscopic submucosal dissection (ESD) has emerged as one of the techniques to successfully resect large colonic polyps en bloc. Complete resection prevents the patient from going through transabdominal colonic resection. We sought to evaluate the proportion of successful en-bloc and complete cure en-bloc resection of large colonic polyps by ESD.MethodsStudies that use ESD technique to resect large colonic polyps were selected. Successful en-bloc resection was defined as resection of the polyp in one piece. Successful complete cure en-bloc resection was defined as one piece with histologic disease-free-margin polyp resection. Articles were searched in Medline, PubMed, and Cochrane control trial registry. Pooled proportions were calculated by both fixed and random-effects model.ResultsThe initial search identified 2,120 reference articles; 389 relevant articles were selected and reviewed. Data were extracted from 14 studies (nxa0=xa01,314) that met the inclusion criteria. The meanxa0±xa0standard error size of the polyps was 30.65xa0±xa02.88xa0mm. Pooled proportion of en-bloc resection by the random-effects model was 84.91% (95% confidence interval, 77.82–90.82) and complete cure en-bloc resection was 75.39% (95% confidence interval, 66.69–82.21). The fixed-effects model was not used because of the heterogeneity of studies.ConclusionsESD should be considered the best minimally invasive endoscopic technique in the treatment of large (>2xa0cm) sessile and flat polyps because it allows full pathological evaluation and cure in most patients. ESD offers an important alternative to surgery in the therapy of large sessile and flat polyps.