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Article ; Online: Effect of the learning curve on survival after laparoscopic liver resection for colorectal metastases.

Shanti, Hiba / Raman, Rakesh / Chakravartty, Saurav / Belgaumkar, Ajay P / Patel, Ameet G

BJS open

2022 Volume 6, Issue 2

Abstract: Background: Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, ... ...

Abstract	Background: Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM). Methods: All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups. Results: A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P = 0.760) were not compromised by the learning curve. The results were replicated after PSM. Conclusion: In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM.
MeSH term(s)	Colorectal Neoplasms/pathology ; Humans ; Laparoscopy/methods ; Learning Curve ; Liver/pathology ; Retrospective Studies
Language	English
Publishing date	2022-04-05
Publishing country	England
Document type	Journal Article
ISSN	2474-9842
ISSN (online)	2474-9842
DOI	10.1093/bjsopen/zrac020
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Article ; Online: Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis.

Zhu, Peng / Dong, Sitong / Sun, Ping / Belgaumkar, Ajay P / Sun, Yi / Cheng, Xiang / Zheng, Qichang / Li, Tong

The Cochrane database of systematic reviews

2023 Volume 8, Page(s) CD012358

Abstract: Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a widely used procedure for management of uncontrolled upper gastrointestinal bleeding and refractory ascites in people with liver cirrhosis. However, nearly half of the people ... ...

Abstract	Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a widely used procedure for management of uncontrolled upper gastrointestinal bleeding and refractory ascites in people with liver cirrhosis. However, nearly half of the people experience shunt dysfunction and recurrent symptoms within one year of the procedure. Expanded polytetrafluoroethylene (ePTFE)-covered stents are assumed to decrease shunt dysfunction by approximately 20% to 30%. Objectives: To evaluate the benefits and harms associated with the use of expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents in transjugular intrahepatic portosystemic shunts (TIPSs) for managing people with liver cirrhosis. Search methods: We used standard, extensive Cochrane search methods. The latest search date was 28 February 2023. Selection criteria: Randomised clinical trials comparing ePTFE-covered stents versus bare stents in TIPS for treatment of people with liver cirrhosis. Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. procedure-related complications, and 3. health-related quality of life. Our secondary outcomes were 4. upper gastrointestinal bleeding, 5. recurrence of ascites, 6. hepatic encephalopathy, 7. kidney failure, 8. early thrombosis, 9. non-serious adverse events, and 10. shunt dysfunction. We used GRADE to assess certainty of evidence. We analysed outcome data at the maximum follow-up, except for the 'early thrombosis' outcome for which it was within 12 weeks after the TIPS procedure. Main results: We included four trials with 565 randomised participants (age range: 18 to 75 years; male range: 63.6% to 75.0%). A total of 527 participants provided data for analyses because of losses to follow-up. Two trials were conducted in China; one in France; and one in France, Spain, and Canada. Participants were classified with cirrhosis Child-Pugh class A, B, or C, and for some, the class was not reported. We used intention-to-treat principle (four trials) and per-protocol analysis (one trial) to meta-analyse the data. One trial compared ePTFE-covered stents versus bare stents of the same diameter and three trials compared ePTFE-covered stents versus stents of different diameters. ePTFE-covered stents versus bare stents of the same diameter One trial with 258 participants compared 8 mm covered stent versus 8 mm bare stent. Mortality in the covered stent group is possibly lower than in the bare stent group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.43 to 0.92; low-certainty evidence). Upper gastrointestinal bleeding (RR 0.54, 95% CI 0.35 to 0.84), recurrence of ascites (RR 0.42, 95% CI 0.20 to 0.87), and shunt dysfunction (RR 0.42, 95% CI 0.28 to 0.61) occurred more often in the bare stent group than in the covered stent group (all low-certainty evidence). There was no difference in hepatic encephalopathy between groups (RR 1.10, 95% CI 0.76 to 1.61; very low-certainty evidence). The trial did not report data on procedure-related complications, health-related quality of life, early thrombosis, and segmental liver ischaemia (a non-serious adverse event). ePTFE-covered stents versus bare stents of different stent diameters Three trials compared ePTFE-covered stents versus bare stents of different diameters (10.5 (standard deviation (SD) 0.9) mm versus 11.7 (SD 0.8) mm; 8 mm versus 10 mm; and one trial used 10-mm stents that could be dilated from 8 mm to 10 mm). There was no evidence of a difference between the ePTFE-covered stents versus bare stents groups in mortality (RR 0.75, 95% CI 0.48 to 1.16; 3 trials, 269 participants), procedure-related complications (RR 0.53, 95% CI 0.05 to 5.57; 1 trial, 80 participants), upper gastrointestinal bleeding (RR 0.46, 95% CI 0.15 to 1.38; 3 trials, 269 participants), hepatic encephalopathy (RR 0.93, 95% CI 0.66 to 1.30; 3 trials, 269 participants), and kidney failure (RR 7.59, 95% CI 0.40 to 143.92; 1 trial, 121 participants) (all very low-certainty evidence). Recurrence of ascites (RR 0.30, 95% CI 0.11 to 0.85; 3 trials, 269 participants; low-certainty evidence), shunt dysfunction (RR 0.50, 95% CI 0.28 to 0.92; 3 trials, 269 participants; low-certainty evidence), and early thrombosis (RR 0.28, 95% CI 0.09 to 0.82; I Authors' conclusions: Based on the small number of trials with insufficient sample size and events, and study limitations, we assessed the overall certainty of evidence in the predefined outcomes as low or very low. Therefore, we are uncertain which of the two interventions (ePTFE-covered stents or bare stents of the same diameter and ePTFE-covered stents versus bare stents of different stent diameters) is effective for the evaluated outcomes. None of the four trials reported data on health-related quality of life, and data on complications were either missing or rarely reported. We lack high-quality trials to evaluate the role of ePTFE-covered stents for TIPS for managing people with liver cirrhosis.
MeSH term(s)	Adolescent ; Adult ; Aged ; Humans ; Male ; Middle Aged ; Young Adult ; Ascites/etiology ; Ascites/therapy ; Gastrointestinal Hemorrhage/etiology ; Hepatic Encephalopathy/etiology ; Liver Cirrhosis/complications ; Polytetrafluoroethylene/adverse effects ; Portasystemic Shunt, Transjugular Intrahepatic/adverse effects ; Portasystemic Shunt, Transjugular Intrahepatic/methods ; Quality of Life ; Stents/adverse effects ; Female ; Randomized Controlled Trials as Topic
Chemical Substances	Polytetrafluoroethylene (9002-84-0)
Language	English
Publishing date	2023-08-02
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Review ; Systematic Review
ISSN	1469-493X
ISSN (online)	1469-493X
DOI	10.1002/14651858.CD012358.pub2
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Article ; Online: A Systematic Review and Meta-analysis of the Effect of Gastric Bypass Surgery on Plasma Lipid Levels.

Carswell, Kirstin A / Belgaumkar, Ajay P / Amiel, Stephanie A / Patel, Ameet G

Obesity surgery

2016 Volume 26, Issue 4, Page(s) 843–855

Abstract: Background: Obesity-related dyslipidaemia comprises hypercholesterolaemia, hypertriglyceridaemia, low HDL-cholesterol and normal to raised LDL-cholesterol levels. 40% of morbidly obese surgical patients have dyslipidaemia. Roux-en-Y gastric bypass (RYGB) ...

Abstract	Background: Obesity-related dyslipidaemia comprises hypercholesterolaemia, hypertriglyceridaemia, low HDL-cholesterol and normal to raised LDL-cholesterol levels. 40% of morbidly obese surgical patients have dyslipidaemia. Roux-en-Y gastric bypass (RYGB) surgery has many beneficial metabolic effects, but the full impact on plasma lipids has not been clearly defined. Methods: A systematic review of electronic databases (Ovid; Medline; PubMed; Embase) between 1960 and March 2012 was performed using search terms including the following: obesity surgery, bariatric surgery, gastric bypass, cholesterol, lipids, triglycerides and non-esterified fatty acids. A total of 2442 manuscripts were screened. Papers with paired plasma lipid levels around RYGB surgery were included. Exclusions included the following: editorials, dual publications, n < 10, resulting in 75 papers of relevance. A meta-analysis was performed of the effect of RYGB surgery upon plasma lipids at different time points up to 4 years following surgery, using a random effects model. Results: Paired data were available for 7815 subjects around RYGB surgery for morbid obesity with a baseline BMI 48 kg/m(2) (n = 2331). There was a reduction in plasma total cholesterol and LDL-C from 1 month up to 4 years post-RYGB (p < 0.00001, p < 0.00001). Following RYGB, HDL-C increased from 1 year onwards (p < 0.00001), and triglyceride levels were reduced postoperatively from 3 months up to 4 years (p < 0.00001). NEFA levels were increased at 1 month postoperatively (p = 0.003), but from 3 months onwards did not differ from preoperative levels (p = 0.07). Conclusions: RYGB surgery reverses the dyslipidaemia of obesity. These findings support the use of RYGB in the management of high cardiovascular risk lipid profiles in morbid obesity.
MeSH term(s)	Cholesterol/blood ; Dyslipidemias/blood ; Dyslipidemias/etiology ; Fatty Acids, Nonesterified/blood ; Gastric Bypass ; Humans ; Lipids/blood ; Obesity, Morbid/blood ; Obesity, Morbid/complications ; Obesity, Morbid/surgery ; Postoperative Period ; Triglycerides/blood
Chemical Substances	Fatty Acids, Nonesterified ; Lipids ; Triglycerides ; Cholesterol (97C5T2UQ7J)
Language	English
Publishing date	2016-04
Publishing country	United States
Document type	Journal Article ; Meta-Analysis ; Review
ZDB-ID	1070827-3
ISSN	1708-0428 ; 0960-8923
ISSN (online)	1708-0428
ISSN	0960-8923
DOI	10.1007/s11695-015-1829-x
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Zs.A 3381: Show issues

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Article ; Online: Post-endoscopic retrograde cholangiography laparoscopic cholecystectomy: challenging but safe.

Mann, Kulbir / Belgaumkar, Ajay P / Singh, Sukhpal

JSLS : Journal of the Society of Laparoendoscopic Surgeons

2013 Volume 17, Issue 3, Page(s) 371–375

Abstract: Background and objectives: Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and ... ...

Abstract	Background and objectives: Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP. Methods: All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC. Results: The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates. Conclusion: Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.
MeSH term(s)	Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy, Laparoscopic ; Female ; Gallstones/surgery ; Humans ; Length of Stay/statistics & numerical data ; Male ; Middle Aged ; Operative Time ; Patient Readmission/statistics & numerical data ; Postoperative Complications/epidemiology ; Reoperation ; Retrospective Studies ; Risk Factors ; Treatment Outcome
Language	English
Publishing date	2013-09-09
Publishing country	United States
Document type	Journal Article
ZDB-ID	2011211-7
ISSN	1938-3797 ; 1086-8089
ISSN (online)	1938-3797
ISSN	1086-8089
DOI	10.4293/108680813X13654754535511
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Zs.A 5183: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (2.OG) ab Jg. 2022: Lesesaal (EG)
Zs.MO 310: Show issues

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Article ; Online: Surgery in Castleman's disease: a systematic review of 404 published cases.

Talat, Nadia / Belgaumkar, Ajay P / Schulte, Klaus-Martin

Annals of surgery

2012 Volume 255, Issue 4, Page(s) 677–684

Abstract: Objectives: We undertook a systematic review of 404 published cases of Castleman's disease to identify the role of the surgeon beyond assistance in tissue-based diagnosis.: Background: Castleman's disease is a rare primary disease of the lymph node ... ...

Abstract	Objectives: We undertook a systematic review of 404 published cases of Castleman's disease to identify the role of the surgeon beyond assistance in tissue-based diagnosis. Background: Castleman's disease is a rare primary disease of the lymph node caused by infection with herpesviridae. Little is known about the role of surgery in this condition. Data sources: Medline, Embase, Cochrane Database of Systematic Reviews, ISI Thompson Web of Knowledge, and hand search of articles' bibliography. Study selection: Of the 1791 citations identified through the initial electronic search and screened for possible inclusion, 488 articles were retained after title and abstract reviews. Of these, 239 were accepted for this review. Data extraction: A complete dataset containing age, gender, centricity (unicentric vs multicentric), histopathologic type (hyaline vascular [HV] vs plasma cell [PC]), anatomical location of the only focus in unicentric Castleman's disease (UCD) or the dominant focus in multicentric Castleman's disease (MCD), nature of the surgical approach (resective vs diagnostic), and outcome (disease-free survival [DFS] vs death due to disease) was extracted. Results: A resective or debulking surgical approach was described in 77.0% of all patients, but was far more common in unicentric (262/278; 94.2%) than multicentric (49/126; 38.9%) disease (χ² 146.8; P < 0.0001). Unicentric disease had a significantly higher overall survival (95.3% vs 61.1%; χ² 55.7; P < 0.0001), 3 year DFS (89.7% vs 55.6%; χ² 27.8; P < 0.0001), and 5 year DFS (81.2% vs 34.4%; χ² 28.6; P < 0.0001) than multicentric disease. Failure to treat unicentric disease by resective surgery resulted in a significant mortality (17.6% vs 3.8% χ²; P < 0.05). In multicentric disease, outcomes are comparable between debulking surgery alone, immunochemotherapy alone, or a combination of both (28.0% vs 28.9% vs 50.0%; P = nonsignificant). Conclusions: Surgery is the gold standard for treatment of unicentric Castelman's disease. The role of debulking surgery in human immunodeficiency virus (-) MCD needs to be evaluated in prospective studies.
MeSH term(s)	Castleman Disease/mortality ; Castleman Disease/pathology ; Castleman Disease/surgery ; Humans ; Survival Rate ; Treatment Outcome
Language	English
Publishing date	2012-04
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0b013e318249dcdc
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Uk I Zs.35/1: Show issues

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Article ; Online: Liver surgery in the multidisciplinary management of gastrointestinal stromal tumour.

Cananzi, Ferdinando C M / Belgaumkar, Ajay P / Lorenzi, Bruno / Mudan, Satvinder

ANZ journal of surgery

2014 Volume 84, Issue 12, Page(s) E1–8

Abstract: Introduction: After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated ... ...

Abstract	Introduction: After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST. Methods: Eleven patients underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed. Results: One and two-year overall survival rates were 80.8 and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1- and 2-year overall survival (OS) rate 100%) than those operated on disease progression (1- and 2-year OS rates 60 and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001). Discussion: R0 resection and clinical response to TKI are predictor of survival. Surgical resection should be performed as soon as feasible in responding patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST.
MeSH term(s)	Adult ; Aged ; Antineoplastic Agents/therapeutic use ; Benzamides/therapeutic use ; Chemotherapy, Adjuvant ; Female ; Follow-Up Studies ; Gastrointestinal Neoplasms/pathology ; Gastrointestinal Stromal Tumors/drug therapy ; Gastrointestinal Stromal Tumors/mortality ; Gastrointestinal Stromal Tumors/secondary ; Gastrointestinal Stromal Tumors/surgery ; Hepatectomy ; Humans ; Imatinib Mesylate ; Liver Neoplasms/drug therapy ; Liver Neoplasms/mortality ; Liver Neoplasms/secondary ; Liver Neoplasms/surgery ; Male ; Middle Aged ; Neoadjuvant Therapy ; Piperazines/therapeutic use ; Pyrimidines/therapeutic use ; Retrospective Studies ; Survival Analysis ; Treatment Outcome
Chemical Substances	Antineoplastic Agents ; Benzamides ; Piperazines ; Pyrimidines ; Imatinib Mesylate (8A1O1M485B)
Language	English
Publishing date	2014-12
Publishing country	Australia
Document type	Evaluation Studies ; Journal Article
ZDB-ID	2050749-5
ISSN	1445-2197 ; 1445-1433 ; 0004-8682
ISSN (online)	1445-2197
ISSN	1445-1433 ; 0004-8682
DOI	10.1111/ans.12195
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Zs.A 180: Show issues

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Article ; Online: Interventions for necrotising pancreatitis.

Gurusamy, Kurinchi Selvan / Belgaumkar, Ajay P / Haswell, Adam / Pereira, Stephen P / Davidson, Brian R

The Cochrane database of systematic reviews

2016 Volume 4, Page(s) CD011383

Abstract: Background: Acute necrotising pancreatitis carries significant mortality, morbidity, and resource use. There is considerable uncertainty as to how people with necrotising pancreatitis should be treated.: Objectives: To assess the benefits and harms ... ...

Abstract	Background: Acute necrotising pancreatitis carries significant mortality, morbidity, and resource use. There is considerable uncertainty as to how people with necrotising pancreatitis should be treated. Objectives: To assess the benefits and harms of different interventions in people with acute necrotising pancreatitis. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 4), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to April 2015 to identify randomised controlled trials (RCT). We also searched the references of included trials to identify further trials. Selection criteria: We considered only RCTs performed in people with necrotising pancreatitis, irrespective of aetiology, presence of infection, language, blinding, or publication status for inclusion in the review. Data collection and analysis: Two review authors independently identified trials and extracted data. We calculated the odds ratio (OR) and mean difference with 95% confidence intervals (CI) using Review Manager 5 based on an available-case analysis using fixed-effect and random-effects models. We planned a network meta-analysis using Bayesian methods, but due to sparse data and uncertainty about the transitivity assumption, performed only indirect comparisons and used Frequentist methods. Main results: We included eight RCTs with 311 participants in this review. After exclusion of five participants, we included 306 participants in one or more outcomes. Five trials (240 participants) investigated the three main treatments: open necrosectomy (121 participants), minimally invasive step-up approach (80 participants), and peritoneal lavage (39 participants) and were included in the network meta-analysis. Three trials (66 participants) investigated the variations in the main treatments: early open necrosectomy (25 participants), delayed open necrosectomy (11 participants), video-assisted minimally invasive step-up approach (12 participants), endoscopic minimally invasive step-up approach (10 participants), minimally invasive step-up approach (planned surgery) (four participants), and minimally invasive step-up approach (continued percutaneous drainage) (four participants). The trials included infected or sterile necrotising pancreatitis of varied aetiology.All the trials were at unclear or high risk of bias and the overall quality of evidence was low or very low for all the outcomes. Overall, short-term mortality was 30% and serious adverse events rate was 139 serious adverse events per 100 participants. The differences in short-term mortality and proportion of people with serious adverse events were imprecise in all the comparisons. The number of serious adverse events and adverse events were fewer in the minimally invasive step-up approach compared to open necrosectomy (serious adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study; adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study). The proportion of people with organ failure and the mean costs were lower in the minimally invasive step-up approach compared to open necrosectomy (organ failure: OR 0.20, 95% CI 0.07 to 0.60; 88 participants; 1 study; mean difference in costs: USD -11,922; P value < 0.05; 88 participants; 1 studies). There were more adverse events with video-assisted minimally invasive step-up approach group compared to endoscopic-assisted minimally invasive step-up approach group (rate ratio 11.70, 95% CI 1.52 to 89.87; 22 participants; 1 study), but the number of interventions per participant was less with video-assisted minimally invasive step-up approach group compared to endoscopic minimally invasive step-up approach group (difference in medians: 2 procedures; P value < 0.05; 20 participants; 1 study). The differences in any of the other comparisons for number of serious adverse events, proportion of people with organ failure, number of adverse events, length of hospital stay, and intensive therapy unit stay were either imprecise or were not consistent. None of the trials reported long-term mortality, infected pancreatic necrosis (trials that included participants with sterile necrosis), health-related quality of life at any time frame, proportion of people with adverse events, requirement for additional invasive intervention, time to return to normal activity, and time to return to work. Authors' conclusions: Low to very low quality evidence suggested that the minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. Very low quality evidence suggested that the endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment. There is currently no evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy. However, the CIs were wide and significant benefits or harms of different treatments cannot be ruled out. The TENSION trial currently underway in Netherlands is assessing the optimal way to perform the minimally invasive step-up approach (endoscopic drainage followed by endoscopic necrosectomy if necessary versus percutaneous drainage followed by video-assisted necrosectomy if necessary) and is assessing important clinical outcomes of interest for this review. Implications for further research on this topic will be determined after the results of this RCT are available.
MeSH term(s)	Humans ; Necrosis/surgery ; Pancreatitis, Acute Necrotizing/therapy ; Peritoneal Lavage ; Randomized Controlled Trials as Topic ; Video-Assisted Surgery/adverse effects
Language	English
Publishing date	2016-04-16
Publishing country	England
Document type	Journal Article ; Meta-Analysis ; Research Support, Non-U.S. Gov't ; Review ; Systematic Review
ISSN	1469-493X
ISSN (online)	1469-493X
DOI	10.1002/14651858.CD011383.pub2
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Article ; Online: Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery.

Bond-Smith, Giles / Belgaumkar, Ajay P / Davidson, Brian R / Gurusamy, Kurinchi Selvan

The Cochrane database of systematic reviews

2016 Volume 2, Page(s) CD011382

Abstract: Background: 'Fast-track surgery' or 'enhanced recovery protocol' or 'fast-track rehabilitation', incorporating one or more elements of preoperative education, pain relief, early mobilisation, enteral nutrition and growth factors, may improve health- ... ...

Abstract	Background: 'Fast-track surgery' or 'enhanced recovery protocol' or 'fast-track rehabilitation', incorporating one or more elements of preoperative education, pain relief, early mobilisation, enteral nutrition and growth factors, may improve health-related quality of life and reduce length of hospital stay and costs. The role of enhanced recovery protocols in major upper gastrointestinal, liver and pancreatic surgery is unclear. Objectives: To assess the benefits and harms of enhanced recovery protocols compared with standard care (or usual practice) in major upper gastrointestinal, liver and pancreatic surgery. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until March 2015 to identify randomised trials. We also searched the references of included trials to identify further trials. Selection criteria: We considered only randomised controlled trials (RCTs) performed in people undergoing major upper gastrointestinal, liver and pancreatic surgery, irrespective of language, blinding or publication status for inclusion in the review. Data collection and analysis: Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CIs) using both fixed-effect and random-effects models using Review Manager 5, based on available case analysis. Main results: Ten studies met the inclusion criteria for the review, and nine studies provided information on one or more outcomes for the review. A total of 1014 participants were randomly assigned to the enhanced recovery protocol (499 participants) or standard care (515 participants) in the nine RCTs. Most of the trials included low anaesthetic risk participants with high performance status undergoing different upper gastrointestinal, liver and pancreatic surgeries. Eight trials incorporated more than one element of the enhanced recovery protocol. All of the trials were at high risk of bias. The overall quality of evidence was low or very low.None of the trials reported long-term mortality, medium-term health-related quality of life(three months to one year), time to return to normal activity, or time to return to work. The difference between the enhanced recovery protocol and standard care were imprecise for short-term mortality (enhanced recovery protocol: 4/425 (adjusted proportion = 0.6%); standard care: 1/443 (0.2%); seven trials; 868 participants; RR 2.79; 95% CI 0.44 to 17.73; very low quality evidence), proportion of people with serious adverse events (enhanced recovery protocol: 4/157 (adjusted proportion = 0.6%); standard care: 0/184 (0.0%); two trials; 341 participants; RR 5.57; 95% CI 0.68 to 45.89; very low quality evidence), number of serious adverse events (enhanced recovery protocol: 34/421 (8 per 100 participants); standard care: 46/438 (11 per 100 participants); seven trials; 859 participants; rate ratio 0.72; 95% CI 0.45 to 1.13; very low quality evidence), health-related quality of life (four trials; 373 participants; SMD 0.29; 95% CI -0.04 to 0.62; very low quality evidence) and hospital readmissions (enhanced recovery protocol: 14/355 (adjusted proportion = 3.3%); standard care: 9/378 (2.4%); seven trials; 733 participants; RR 1.4; 95% CI 0.69 to 2.87; very low quality evidence). The enhanced recovery protocol group had a lower proportion of people with mild adverse events (enhanced recovery protocol: 31/254 (adjusted proportion = 10.9%); standard care: 51/271 (18.8%); four trials; 525 participants; RR 0.58; 95% CI 0.39 to 0.85; low quality evidence), fewer number of mild adverse events (enhanced recovery protocol: 69/499 (13 per 100 participants); standard care: 128/515 (25 per 100 participants); nine trials; 1014 participants; rate ratio 0.52; 95% CI 0.39 to 0.70; low quality evidence), shorter length of hospital stay (nine trials; 1014 participants; MD -2.19 days; 95% CI -2.53 to -1.85; low quality evidence) and lower costs (four trials; 282 participants; MD USD -6300; 95% CI -8400 to -4200; low quality evidence) than standard care group. Authors' conclusions: Based on low quality evidence, enhanced recovery protocols may reduce length of hospital stay and costs (primarily because of reduction in hospital stay) in people undergoing major upper gastrointestinal, liver and pancreatic surgeries. However, the validity of the results is uncertain because of the risk of bias in the trials and the way the outcomes were measured. Future RCTs should be conducted with low risk of bias, and measure clinically important outcomes for including the three months to one year period.
MeSH term(s)	Clinical Protocols ; Digestive System Surgical Procedures ; Early Ambulation ; Enteral Nutrition ; Esophagectomy ; Gastrectomy ; Humans ; Length of Stay ; Liver/surgery ; Pain Management ; Pancreas/surgery ; Preoperative Care ; Quality of Life ; Randomized Controlled Trials as Topic ; Standard of Care
Language	English
Publishing date	2016-02-01
Publishing country	England
Document type	Journal Article ; Meta-Analysis ; Research Support, Non-U.S. Gov't ; Review ; Systematic Review
ISSN	1469-493X
ISSN (online)	1469-493X
DOI	10.1002/14651858.CD011382.pub2
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Article ; Online: Chemotherapy before liver resection of colorectal metastases: friend or foe?

Belgaumkar, Ajay P / Low, Nadeen / Riga, Angela T / Worthington, Tim R / Karanjia, Nariman D

Annals of surgery

2015 Volume 261, Issue 2, Page(s) e36

MeSH term(s)	Antineoplastic Agents/therapeutic use ; Colorectal Neoplasms/pathology ; Humans ; Liver Neoplasms/drug therapy ; Liver Neoplasms/surgery
Chemical Substances	Antineoplastic Agents
Language	English
Publishing date	2015-02
Publishing country	United States
Document type	Comment ; Letter
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000000807
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Article ; Online: Pharmacological interventions for acute pancreatitis.

Moggia, Elisabetta / Koti, Rahul / Belgaumkar, Ajay P / Fazio, Federico / Pereira, Stephen P / Davidson, Brian R / Gurusamy, Kurinchi Selvan

The Cochrane database of systematic reviews

2017 Volume 4, Page(s) CD011384

Abstract: Background: In people with acute pancreatitis, it is unclear what the role should be for medical treatment as an addition to supportive care such as fluid and electrolyte balance and organ support in people with organ failure.: Objectives: To assess ... ...

Abstract	Background: In people with acute pancreatitis, it is unclear what the role should be for medical treatment as an addition to supportive care such as fluid and electrolyte balance and organ support in people with organ failure. Objectives: To assess the effects of different pharmacological interventions in people with acute pancreatitis. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 9), MEDLINE, Embase, Science Citation Index Expanded, and trial registers to October 2016 to identify randomised controlled trials (RCTs). We also searched the references of included trials to identify further trials. Selection criteria: We considered only RCTs performed in people with acute pancreatitis, irrespective of aetiology, severity, presence of infection, language, blinding, or publication status for inclusion in the review. Data collection and analysis: Two review authors independently identified trials and extracted data. We did not perform a network meta-analysis as planned because of the lack of information on potential effect modifiers and differences of type of participants included in the different comparisons, when information was available. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) for the binary outcomes and rate ratios with 95% CIs for count outcomes using a fixed-effect model and random-effects model. Main results: We included 84 RCTs with 8234 participants in this review. Six trials (N = 658) did not report any of the outcomes of interest for this review. The remaining 78 trials excluded 210 participants after randomisation. Thus, a total of 7366 participants in 78 trials contributed to one or more outcomes for this review. The treatments assessed in these 78 trials included antibiotics, antioxidants, aprotinin, atropine, calcitonin, cimetidine, EDTA (ethylenediaminetetraacetic acid), gabexate, glucagon, iniprol, lexipafant, NSAIDs (non-steroidal anti-inflammatory drugs), octreotide, oxyphenonium, probiotics, activated protein C, somatostatin, somatostatin plus omeprazole, somatostatin plus ulinastatin, thymosin, ulinastatin, and inactive control. Apart from the comparison of antibiotics versus control, which included a large proportion of participants with necrotising pancreatitis, the remaining comparisons had only a small proportion of patients with this condition. Most trials included either only participants with severe acute pancreatitis or included a mixture of participants with mild acute pancreatitis and severe acute pancreatitis (75 trials). Overall, the risk of bias in trials was unclear or high for all but one of the trials. Source of funding: seven trials were not funded or funded by agencies without vested interest in results. Pharmaceutical companies partially or fully funded 21 trials. The source of funding was not available from the remaining trials.Since we considered short-term mortality as the most important outcome, we presented only these results in detail in the abstract. Sixty-seven studies including 6638 participants reported short-term mortality. There was no evidence of any differences in short-term mortality in any of the comparisons (very low-quality evidence). With regards to other primary outcomes, serious adverse events (number) were lower than control in participants taking lexipafant (rate ratio 0.67, 95% CI 0.46 to 0.96; N = 290; 1 study; very low-quality evidence), octreotide (rate ratio 0.74, 95% CI 0.60 to 0.89; N = 770; 5 studies; very low-quality evidence), somatostatin plus omeprazole (rate ratio 0.36, 95% CI 0.19 to 0.70; N = 140; 1 study; low-quality evidence), and somatostatin plus ulinastatin (rate ratio 0.30, 95% CI 0.15 to 0.60; N = 122; 1 study; low-quality evidence). The proportion of people with organ failure was lower in octreotide than control (OR 0.51, 95% CI 0.27 to 0.97; N = 430; 3 studies; very low-quality evidence). The proportion of people with sepsis was lower in lexipafant than control (OR 0.26, 95% CI 0.08 to 0.83; N = 290; 1 study; very low-quality evidence). There was no evidence of differences in any of the remaining comparisons in these outcomes or for any of the remaining primary outcomes (the proportion of participants experiencing at least one serious adverse event and the occurrence of infected pancreatic necrosis). None of the trials reported heath-related quality of life. Authors' conclusions: Very low-quality evidence suggests that none of the pharmacological treatments studied decrease short-term mortality in people with acute pancreatitis. However, the confidence intervals were wide and consistent with an increase or decrease in short-term mortality due to the interventions. We did not find consistent clinical benefits with any intervention. Because of the limitations in the prognostic scoring systems and because damage to organs may occur in acute pancreatitis before they are clinically manifest, future trials should consider including pancreatitis of all severity but power the study to measure the differences in the subgroup of people with severe acute pancreatitis. It may be difficult to power the studies based on mortality. Future trials in participants with acute pancreatitis should consider other outcomes such as complications or health-related quality of life as primary outcomes. Such trials should include health-related quality of life, costs, and return to work as outcomes and should follow patients for at least three months (preferably for at least one year).
MeSH term(s)	Acute Disease ; Anti-Bacterial Agents/adverse effects ; Anti-Bacterial Agents/therapeutic use ; Antioxidants/adverse effects ; Antioxidants/therapeutic use ; Confidence Intervals ; Gastrointestinal Agents/adverse effects ; Gastrointestinal Agents/therapeutic use ; Humans ; Pancreatitis/drug therapy ; Pancreatitis/mortality ; Pancreatitis, Acute Necrotizing/drug therapy ; Pancreatitis, Acute Necrotizing/mortality ; Probiotics/adverse effects ; Probiotics/therapeutic use ; Randomized Controlled Trials as Topic
Chemical Substances	Anti-Bacterial Agents ; Antioxidants ; Gastrointestinal Agents
Language	English
Publishing date	2017-04-21
Publishing country	England
Document type	Journal Article ; Meta-Analysis ; Review ; Systematic Review
ISSN	1469-493X
ISSN (online)	1469-493X
DOI	10.1002/14651858.CD011384.pub2
Database	MEDical Literature Analysis and Retrieval System OnLINE

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