荟萃分析:肥胖与胃食管反流病及其并发症发生的风险性

Background: The association of body mass index and gastroesophageal reflux disease (CERD), including its complications (esophagitis, Barrett esophagus, and esophageal adenocarcinoma), is unclear. Purpose: To conduct a systematic review and meta- analysis to estimate the magnitude and determinants of an association between obesity and GERD symptoms, erosive esophagitis, Barrett esophagus, and adenocarcinoma of the esophagus and of the gastric cardia. Data Sources: MEDLINE search between 1966 and October 2004 for published full studies. Study Selection: Studies that provided risk estimates and met criteria on defining exposure and reporting outcomes and sample size. Data Extraction: Two investigators independently performed standardized search and data abstraction. Unadjusted and adjusted odds ratios for individual outcomes were obtained or calculated for each study and were pooled by using a random- effects model. Data Synthesis: Nine studies examined the association of body mass index (BMI) with GERD symptoms. Six of these studies found statistically significant associations. Six of 7 studies found significant associations of BMI with erosive esophagitis, 6 of 7 found significant associations with esophageal adenocarcinoma, and 4 of 6 found significant associations with gastric cardia adenocarcinoma. In data from 8 studies, there was a trend toward a dose- response relationship with an increase in the pooled adjusted odds ratios for GERD symptoms of 1.43 (95% CI, 1.158 to 1.774) for BMI of 25 kg/m2 to 30 kg/m2 and 1.94 (CI, 1.468 to 2.566) for BMI greater than 30 kg/m 2. Similarly, the pooled adjusted odds ratios for esophageal adenocarcinoma for BMI of 25 kg/m2 to 30 kg/m2 and BMI greater than 30 kg/m2 were 1.52 (CI, 1.147 to 2.009) and 2.78 (CI, 1.850 to 4.164), respectively. Limitations: Heterogeneity in the findings was present, although it was mostly in the magnitude of statistically significant positive associations. No studies in this review examined the association between Barrett esophagus and obesity. Conclusion: Obesity is associated with a statistically significant increase in the risk for CERD symptoms, erosive esophagitis, and esophageal adenocarcinoma. The risk for these disorders seems to progressively increase with increasing weight.

纯切割电刀电流用于内镜下括约肌切开术与ERCP术后胰腺炎风险:一项前瞻性随机试验

Background: It has been suggested that the use of pure-cut electrosurgical current for endoscopic sphincterotomy may reduce the risk of post-ERCP pancreatit is. The aim of this study was to determine whether pure-cut current reduces the risk of pancreatitis compared with blend current. Methods: Patients were randomly assigned to undergo sphincterotomy over a non-conductive guidewire with 30 W /sec pure-cut current or 30 W/sec blend-2 current by a blinded endoscopist. Serum amylase and lipase levels were determined 1 day before and within 24 hours after ERCP. Post-ERCP pancreatitis was the primary outcome of interest. Secondary outcomes were as follows: severity of immediate bleeding, as graded by a 3-po int scale from 1 (no bleeding) to 3 (injection or balloon tamponade therapy requ ired to stop bleeding) and evidence of delayed bleeding 24 hours after ERCP. Ana lyses were performed in intention-to treat fashion. Results: A total of 246 patients were randomized (116 pure-cut current, 130 blend current). There were no differences in baseline characteristics between the groups. The overall frequency of post-ERCP pancreatitis was 6.9%, with no significant difference in frequ ency between treatment arms (pure cut, 7.8%vs. blend, 6.1%; p = 0.62). The dif ference in rates of pancreatitis between the two groups was 1.7%: 95%CI[-4.8 %, 8.2%]. Six patients (2.4%) had delayed bleeding after ERCP, of which two required transfusion. There was a significant increase in minor bleeding episodes (grade 2) in the pure-cut group (p < 0.0001). Delayed episodes of bleeding were equal (n = 3) in each arm. Conclusions: The type of current used when performing endoscopic sphincterotomy does not appear to alter the risk of post-ERCP pan creatitis. The selection of electrosurgical current for biliary endoscopic sphin cterotomy should be based on endoscopist preference.

5F和4F括约肌切开器对于选择性胆总管插管术的效果相同

Background:Cannulation of the common bile duct(CBD)is the first step in endoscopic retrograde cholangiopancreatography(ERCP).Cannulation difficulty is a known risk factor for post-ERCP complications and may be minimized by the use of a smaller caliber sphincterotome.Objective:To compare the efficacy of CBD cannulation with a 4 F versus a 5 F sphincterotome.Design:A randomized controlled trial,with concealed allocation and double-blinding.Patients:Adult patients undergoing their first ERCP at a tertiary referral center.Intervention:Patients were randomized to undergo CBD cannulation with either a 4 F or 5 F sphincterotome.Main Outcome Measurements:Successful deep cannulation in < 15 attempts was the primary outcome.Secondary outcomes included number of attempts/time to cannulation,incidence of complications within 24 hours,and overall cannulation success(including patients before and after crossover).Analysis was intention to treat and included standard descriptive and inferential methods.Results:A total of 107 patients were randomized:51(4 F)versus 56(5 F).The majority were female(71%)and white(92%).Baseline demographics,presenting symptoms,and laboratory values were similar between groups.Similar success in initial cannulation was observed:84.3%(4 F)and 83.9%(5 F).No differences were noted in time to cannulation(5.12 min SD,4.8 for 4 F vs 4.46 min SD,4.13 for 5 F;p = NS),number of attempts to cannulation(6.2 SD,5.2 for 4 F vs 5.7 SD,4.9 for 5 F;p = NS),or complications.The overall cannulation success was 92.2%(4 F)and 92.9%(5 F).Limitations:Premature termination of the trial resulted in decreased power.Conclusions:There exists no significant difference in efficacy between 4 F and 5 F sphincterotomes.The choice of initial sphincterotome should be dictated by physician preference.