Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07‒0.51; p = 0.009 I² = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06‒0.33; p < 0.0001; I² = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05‒0.16; p < 0.0001; I² = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 ‒ -2,43; p < 0.00001; I² = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 ‒ -0.11; p < 0.00001; I² = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01‒0.15; p = 0.02; I² = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases

Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: systematic review and metaanalysis

Introdução: os defeitos transmurais do trato gastrointestinal alto são um desafio terapêutico em todo o mundo. Fístulas, deiscências e perfurações representam um alto custo para os sistemas de saúde e determinam grande morbidade e mortalidade para os pacientes acometidos. O tratamento endoscópico mais difundido no mundo até então se dá pelo uso de próteses metálicas autoexpansíveis (PMAE). Todavia, apesar de validado, este tratamento apresenta complicações, tais como migração. Estudos recentes apontam bons resultados do uso de terapia endoscópica a vácuo (TEV) no tratamento de defeitos transmurais do trato digestivo superior. Objetivo: comparar, por meio de uma revisão sistemática com metanálise, os stents metálicos autoexpansíveis com a terapia endoscópica a vácuo no tratamento dos defeitos transmurais do trato digestivo superior com base no índice de fechamento dos defeitos transmurais, mortalidade, duração do tratamento, duração da internação hospitalar e eventos adversos. Métodos: buscas foram realizadas no MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS) e literatura cinzenta, bem como busca manual para identificar estudos comparando stents metálicos autoexpansíveis e terapia endoscópica a vácuo. Os dados provenientes dos estudos selecionados foram metanalizados de acordo com as normativas do Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Resultados: a busca final resultou em um total de 11.455 estudos, dentre os quais foram selecionados seis trabalhos, perfazendo um total de 301 pacientes incluídos na análise. A terapia endoscópica a vácuo demonstrou-se superior em relação à sucesso no fechamento do defeito transmural (DR 0,24 [0,13, 0,34], p < 0,0001, I² = 39%), mortalidade (DR 0,10 [0,02, 0,18], p = 0,02, I² = 31%), duração do tratamento endoscópico (MD - 14,97 [-20,52, -9,43], p < 0,00001, I² = 0%) e efeitos adversos (DR 0,25 [0,03, 0,47], p = 0,02, I² = 87%). Não houve significância estatística em relação à duração da internação hospitalar. Conclusão: a terapia endoscópica a vácuo é superior às próteses metálicas autoexpansíveis no tratamento dos defeitos transmurais do trato digestivo superior alto com relação a taxa de sucesso no fechamento do defeito transmural, mortalidade, duração do tratamento endoscópico e eventos adversosIntroduction: upper gastrointestinal transmural defects are a therapeutic challenge worldwide. Fistulas, dehiscence and perforations represent a high cost to health systems and are associated with great morbidity and mortality for affected patients. The most widespread endoscopic treatment in the world so far is self-expanding metal stents. However, despite being validated, this treatment has adverse events, such as migration. Current literature shows good results from the use of endoscopic vacuum therapy in the treatment of upper gastrointestinal transmural defects. Objectives: the aim of this study is to compare, through a systematic review and meta-analysis, endoscopic vacuum therapy versus self-expanding metal stent in the management of upper gastrointestinal transmural defects based on successful closure rate, mortality, duration of the treatment, hospital stay, and adverse events. Methods: searches were performed on MEDLINE MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events. Results: out of an initial 11,455 studies, 6 studies with a total of 301 patients. There was a 24% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.24 [0.13, 0.34], p < 0.0001, I² = 39%). EVT demonstrated a 10% reduction in mortality compared to stenting (RD 0.10 [0.02, 0.18], p = 0.02, I² = 31%) and an average reduction of 14.97 days in duration of treatment (MD - 14.97 [-20.52, -9.43], p < 0.00001, I² = 0%). EVT is even superior SEMS regarding adverse events (RD 0.25 [0.03, 0.47], p = 0.02, I² = 87%). There were no statistical differences between the studied therapies regarding the length of hospital stay. Conclusion: endoscopic vacuum therapy is superior to self-expanding metal stents in the management of upper gastrointestinal transmural defects regarding successful closure rate, mortality, duration of endoscopic treatment and adverse event