Introduction

There are two types of covered self-expandable metallic stents (CSEMS): laser-cut (L) and braided (B). The B-type has a strong axial force and can cause problems such as recurrent obstructive jaundice and cholangitis. The L-type is less stressful for the bile duct.

Aims & Methods

This study aims to compare CSEMS B-type versus L-type in patients with unresectable distal malignant biliary obstruction. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies comparing both types of CSEMS in this population. The primary outcome was stent occlusion. The secondary outcomes were tumor ingrowth, tumor overgrowth, stent migration, pancreatitis and cholecystitis. The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 4 studies and 430 patients. There was no significant difference for any outcome: stent occlusion (OR 1.28; 95% CI 0.73 to 2.23; p=0.388; I²=0%), tumor ingrowth (OR 1.12; 95% CI 0.46 to 2.76; p=0.800; I²=0%), tumor overgrowth (OR 1.23; 95% CI 0.36 to 4.25; p=0.740; I²=0%), stent migration (OR 1.60; 95% CI 0.28 to 9.20; p=0.600; I²=73%), pancreatitis (OR 1.28; 95% CI 0.53 to 2.90; p=0.559; I²=0%) and cholecystitis (OR 0.73; 95% CI 0.26 to 2.06; p=0.553; I²=0%).

Conclusion

In patients with distal malignant biliary obstruction, no significant difference was observed between CSEMS B-type and L-type.

References

1. HASEGAWA, S. et al. Braided-type stent versus laser-cut-type stent for patients with unresectable distal malignant biliary obstruction: a randomized controlled trial. Gastrointestinal Endoscopy, v. 99, n. 5, p. 739-746.e1, 1 maio 2024.
2. OKUNO, M. et al. The evaluation of bilateral stenting using braided or laser-cut self-expandable metallic stent for malignant hilar biliary obstruction. Surgical Endoscopy, v. 37, n. 11, p. 8489–8497, 1 nov. 2023.
‌3. KITAGAWA, K. et al. Laser-cut-type versus braided-type covered self-expandable metallic stents for distal biliary obstruction caused by pancreatic carcinoma: a retrospective comparative cohort study. Clinical Endoscopy, v. 55, n. 3, p. 434–442, 1 maio 2022.
​4. TANISAKA, Y. et al. Can the laser-cut covered self-expandable metallic stent be the first choice for patients with unresectable distal malignant biliary obstruction? (with video). Journal of Hepato-Biliary-Pancreatic Sciences, v. 29, n. 5, p. 585–593, 1 maio 2022.
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Introduction

Endoscopic drainage of malignant biliary obstruction using metal stents is widely used to treat obstructive jaundice. However, the occurrence of stent occlusion or migration raises the hypothesis using stents with larger diameters may be associated with better outcomes.

Aims & Methods

PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) and observational studies comparing 10-mm vs. 12-mm metallic stents for recurrent unresectable biliary obstruction. The primary outcome was stent obstruction. Secondary outcomes included overall adverse events and stent migration. Statistical analyses were performed using R software version 4.3.1. The odds ratio (OR) was used for binary outcomes, and the mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

We included six studies comprising 592 patients who underwent stent placement. Of those, 328 patients received a 10mm and 264 patients a 12mm stent. 12mm stent is associated with a lower incidence of stent obstruction (OR 0.48; 95% CI 0.27 to 0.88; p=0.02; I²=53%). However, no statistically significant differences between groups were found for stent migration (OR 0.68; 95% CI 0.39 to 1.19; p=0.18; I²=0%) and incidence of adverse events (OR 0.84; 95% CI 0.39 to 1.82;p= 0.66; I²=46%).

Conclusion

12-mm metallic stents significantly reduce the incidence of stent obstruction compared to 10-mm stents in managing recurrent unresectable biliary obstruction. However, our analysis did not demonstrate statistically significant differences between the two stent sizes regarding stent migration and overall adverse events.

References

1. CHIKUGO, K. et al. Re-intervention with 10-mm vs 12-mm covered self-expandable metallic stent for recurrent unresectable distal biliary obstruction in patients with previous stent implantation. Journal of Hepato-Biliary-Pancreatic Sciences.
‌2. NAKAOKA, K. et al. Evaluation of a 12-mm diameter covered self-expandable end bare metal stent for malignant biliary obstruction. Endoscopy International Open.
‌3. LEE, H. W. et al. Usefulness of newly modified fully covered metallic stent of 12 mm in diameter and anti-migration feature for periampullary malignant biliary strictures: Comparison with conventional standard metal stent. Journal of Gastroenterology and Hepatology.
‌4. MUKAI, T. et al. Comparison of covered self-expandable metallic stents with 12-mm and 10-mm diameters for unresectable malignant distal biliary obstructions: a prospective randomized trial. Gastrointestinal Endoscopy.
‌5. DO, M. Y. et al. Safety and Efficacy of a Large-Bore Biliary Metallic Stent for Malignant Biliary Obstruction. Journal of Clinical Medicine.
6. CAILLOL, F. et al. Evaluation of a new metal biliary stent of 12-mm diameter: A case control study. Jounal of Gastrointestinal and Digestive System​.
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Introduction

Malignant biliary obstruction (MBO) encompasses a variety of malignancies arising from the pancreaticobiliary system. The relatively common occurrence of duodenobiliary reflux (DBR) in patients with transpapillary stent placement for palliative management raises the importance of the development of alternative methods to prevent adverse outcomes.

Aims & Methods

We aimed to compare supra-papillary to trans-papillary stenting in patients with MBO for stent dysfunction and adverse events. PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs). The primary outcome was stent occlusion. Secondary outcomes included stent migration, occurrence of cholangitis or pancreatitis, cumulative duration of stent patency in days, and patient survival in days. Statistical analyses were conducted using R (version 4.3.1) and a random-effects model was employed.

Results

We found 3 RCTs with 161 patients (80 in the supra-papilla stent group vs. 81 in the trans-papilla group). Supra-papillary stent placement was associated with significantly lower rates of stent occlusion (OR 0.42; 95% CI 0.20 to 0.87; p = 0.019), and longer cumulative duration of stent patency (MD 77.59; 95% CI 23.84 to 131.34; p < 0.01). The Trial Sequential Analysis for this outcome showed that this study has surpassed the required information size (n = 158) to ascertain the statistical difference for this outcome. The analyses of stent migration (p = 0.471) occurrence of cholangitis (p = 0.525), and patient survival (p = 0.05) revealed no significant difference between both groups.

Conclusion

We found a significant improvement in stent occlusion rates and cumulative duration of stent patency favoring the supra-papilla group, with no difference for stent migration, occurrence of cholangitis, and patient survival for this comparison.

Introduction

Iodinated contrast (IC) is one of the leading causes of acute kidney injury (AKI). Nephrotoxicity of IC in cirrhosis is a debated issue due to low-quality evidence.

Aims & Methods

This study aims to evaluate the association between exposition to IC in cirrhotic patients and the development of AKI. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies conducted in cirrhotic patients exposed to IC. The primary outcomes were: 1) AKI development in cirrhotic patients exposed or not to IC; and 2) AKI development in cirrhotic and health patients exposed to IC. The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 4 studies and 1,055 patients. Three studies (911 patients) evaluated cirrhotic patients exposed or not exposed to IC. There was a significant increase in AKI in cirrhotic patients exposed to IC (OR 3.10; 95% CI 1.45 to 6.61, p=0.003; I2=0%). Three studies (654 patients) evaluated cirrhotic and health patients exposed to IC. There was no difference in AKI comparing both groups (OR 1.61; 95% CI 0.63 to 4.16, p=0.322; I2=0%).

Conclusion

Patients with cirrhosis exposed to IC showed higher incidence of AKI compared with those not exposed, but when compared with health individuals also exposed to IC the incidence of AKI seems to be the same.

References

1. Campion D, Rizzo M, Ponzo P, Risso A, Giovo I, Rizzi F, et al. Risk of contrast-induced acute kidney injury in cirrhotic patients undergoing computed tomography: myth or reality? J Hepatol. 2020;73:S702.
2. Campion D, Ponzo P, Risso A, Caropreso P, Caviglia GP, Sanavia T, et al. A prospective, multicenter, three-cohort study evaluating contrast-induced acute kidney injury (CI-AKI) in patients with cirrhosis. J Hepatol. 2024;80(1):62–72.
3. Filomia R, Maimone S, Caccamo G, Saitta C, Visconti L, Alibrandi A, et al. Acute kidney injury in cirrhotic patients undergoing contrast-enhanced computed tomography. Medicine (Baltimore). 2016 Sep;95(38):e4836.
4. Safi W, Rauscher I, Umgelter A. Contrast-induced acute kidney injury in cirrhotic patients. A retrospective analysis. Ann Hepatol. 2015 Nov;14(6):895–901.
5. Visconti L, Filomia R, Maimone S, Montuori F, Ricciardi CA, Di Mauro E, et al. SP211ACUTE KIDNEY INJURY IN CIRRHOTIC PATIENTS UNDERGOING CONTRAST-ENHANCED COMPUTED TOMOGRAPHY. Nephrol Dial Transplant. 2015 May;30(suppl_3):iii448–iii448.

Introduction

Renal impairment is a common complication in cirrhosis. Urinary neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in diagnosis of the different types of acute kidney injury (AKI) in cirrhosis.

Aims & Methods

This study aims to evaluate the accuracy of NGAL in the differential diagnosis of acute tubular necrosis (ATN) in cirrhosis. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies analyzing NGAL as a biomarker of ATN. Statistical analysis included data pooling and heterogeneity testing. Quality of the included studies was assessed by Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2).

Results

The meta-analyses included 3 studies and 317 patients. The NGAL cut-off evaluated were similar between the three studies (delta 143 to 244μg/g). The pooled sensitivity and specificity of NGAL in predicting ATN in cirrhosis were 78.7% (95% CI 68.4% to 86.4%) and 80.8% (95% CI 55.5% to 93.4%). The AUC was 0.866 (95% CI 0.646 to 0.955).

Conclusion

In patients with cirrhosis, urinary NGAL is a good predictor of ATN and can be used as an additional tool to the differential diagnosis of acute kidney injury.

Introduction

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths. Unresectable HCC can be treated with transarterial chemoembolization (TACE), which causes hypoxia and induces the expression of vascular endothelial growth factor (VEGF). Antiangiogenic drugs can be useful in this setting.

Aims & Methods

This study aims to compare TACE plus Apatinib (antiangiogenic drug, TACE+A) versus TACE plus Apatinib plus Camrelizumab (immune checkpoint inhibitor, TACE+AC). We performed a systematic review in PubMed, Embase, Cochrane and Web of Science databases, searching for studies comparing TACE+A versus TACE+AC in patients with unresectable HCC. The primary outcomes were overall survival and disease-free progression survival. The secondary outcomes were treatment response and adverse events grade III or IV. The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics. ​

Results

The meta-analyses included 3 studies and 1,134 patients. There was a significant difference favoring TACE+AC in overall survival (HR 0.41; 95% CI 0.28 to 0.60; p<0.01; I²=87%) and in disease-free progression survival (HR 0.29; 95% CI 0.15 to 0.55; p<0.01; I0²=0%) compared to TACE+A. There is no difference in adverse events grade III or IV between groups (OR 1.08; 95% CI 0.83 to 1.40; p=0.586; I²=0%).

Conclusion

In patients with unresectable HCC, TACE+AC demonstrated superior efficacy compared to TACE+A. The two combinations showed similar safety profiles.

References

1. Duan X, Li H, Kuang D, Chen P, Zhang K, Li Y, et al. Transcatheter arterial chemoembolization plus apatinib with or without camrelizumab for unresectable hepatocellular carcinoma: a multicenter retrospective cohort study. Hepatol Int. 2023 Aug;17(4):915–26.
2. Liu H, Yu Q, Gu T, Qu P, Ma X, Zhou S, et al. Transarterial Chemoembolization plus Apatinib with or without Camrelizumab for the Treatment of Advanced HBV-related Hepatocellular Carcinoma. J Gastrointest Liver Dis JGLD. 2023 Jun 22;32(2):182–9.
3. Zhu D, Ma K, Yang W, Zhou HF, Shi Q, Ren JW, et al. Transarterial chemoembolization plus apatinib with or without camrelizumab for unresected hepatocellular carcinoma: A two-center propensity score matching study. Front Oncol. 2022;12:1057560.

Introduction

Hepatic venous pressure gradient (HVPG) measurement is invasive. Non-invasive methods for evaluating the severity of portal hypertension in patients with transjugular intrahepatic portosystemic shunt (TIPS) are warranted.

Aims & Methods

This study aims to evaluate the efficacy of spleen stiffness in predicting HVPG and TIPS dysfunction. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies comparing spleen stiffness measurements pre-TIPS and post-TIPS. The primary outcome was spleen stiffness. The secondary outcome was spleen stiffness in the context of TIPS dysfunction. The MD was used for continuous outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 13 studies and 521 patients. There was a significant difference in spleen stiffness reduction after TIPS compared to baseline, measured by SSW m/s (MD -0.49; 95% CI -0.55 to -0.43; p<0.01; I²=0%) and by SSM kPa (MD -11.19; 95% CI -13.32 to -9.07; p<0.01; I²=0%). TIPS dysfunction was associated with increased spleen stiffness values (MD 0.35; 95% CI 0.24 to 0.45; p<0.01; I²=0%) compared to normal tips function similarly to those found in pre-TIPS patients.

Conclusion

Our study showed that spleen stiffness is a non-invasive measure to evaluate HPVG reduction after TIPS placement. Spleen stiffness may also be useful in monitoring TIPS dysfunction.