Body-mass index correlates with severity and mortality in acute pancreatitis: A meta-analysis

BACKGROUND Obesity rates have increased sharply in recent decades. As there is a growing number of cases in which acute pancreatitis(AP) is accompanied by obesity, we found it clinically relevant to investigate how body-mass index(BMI) affects the outcome of the disease.AIM To quantify the association between subgroups of BMI and the severity and mortality of AP.METHODS A meta-analysis was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis(PRISMA) Protocols. Three databases(PubMed, EMBASE and the Cochrane Library) were searched for articles containing data on BMI, disease severity and mortality rate for AP. Englishlanguage studies from inception to 19 June 2017 were checked against our predetermined eligibility criteria. The included articles reported all AP cases with no restriction on the etiology of the disease. Only studies that classified AP cases according to the Atlanta Criteria were involved in the severity analyses. Odds ratios(OR) and mean differences(MD) were pooled using the random effects model with the DerSimonian-Laird estimation and displayed on forest plots. The meta-analysis was registered in PROSPERO under number CRD42017077890.RESULTS A total of 19 articles were included in our meta-analysis containing data on 9997 patients. As regards severity, a subgroup analysis showed a direct association between AP severity and BMI. BMI < 18.5 had no significant effect on severity;however, BMI > 25 had an almost three-fold increased risk for severe AP in comparison to normal BMI(OR = 2.87, 95%CI: 1.90-4.35, P < 0.001). Importantly,the mean BMI of patients with severe AP is higher than that of the non-severe group(MD = 1.79, 95%CI: 0.89-2.70, P < 0.001). As regards mortality, death rates among AP patients are the highest in the underweight and obese subgroups. A BMI < 18.5 carries an almost two-fold increase in risk of mortality compared to normal BMI(OR = 1.82, 95%CI: 1.32-2.50, P < 0.001). However, the chance of mortality is almost equal in the normal BMI and BMI 25-30 subgroups. A BMI >30 results in a three times higher risk of mortality in comparison to a BMI < 30(OR = 2.89, 95%CI: 1.10-7.36, P = 0.026).CONCLUSION Our findings confirm that a BMI above 25 increases the risk of severe AP, while a BMI > 30 raises the risk of mortality. A BMI < 18.5 carries an almost two times higher risk of mortality in AP.

One in four patients with gastrointestinal bleeding develops shock or hemodynamic instability:A systematic review and meta-analysis

BACKGROUND Hemodynamic instability and shock are associated with untoward outcomes in gastrointestinal bleeding.However,there are no studies in the existing literature on the proportion of patients who developed these outcomes after gastrointestinal bleeding.AIM To determine the pooled event rates in the available literature and specify them based on the bleeding source.METHODS The protocol was registered on PROSPERO in advance(CRD42021283258).A systematic search was performed in three databases(PubMed,EMBASE,and CENTRAL)on 14^(th) October 2021.Pooled proportions with 95%CI were calculated with a random-effects model.A subgroup analysis was carried out based on the time of assessment(on admission or during hospital stay).Heterogeneity was assessed by Higgins and Thompson’s I^(2) statistics.The Joanna Briggs Institute Prevalence Critical Appraisal Tool was used for the risk of bias assessment.The Reference Citation Analysis(https://www.referencecitationanalysis.com/)tool was applied to obtain the latest highlight articles.RESULTS We identified 11589 records,of which 220 studies were eligible for data extraction.The overall proportion of shock and hemodynamic instability in general gastrointestinal bleeding patients was 0.25(95%CI:0.17-0.36,I^(2)=100%).In non-variceal bleeding,the proportion was 0.22(95%CI:0.14-0.31,I^(2)=100%),whereas it was 0.25(95%CI:0.19-0.32,I^(2)=100%)in variceal bleeding.The proportion of patients with colonic diverticular bleeding who developed shock or hemodynamic instability was 0.12(95%CI:0.06-0.22,I^(2)=90%).The risk of bias was low,and heterogeneity was high in all analyses.CONCLUSION One in five,one in four,and one in eight patients develops shock or hemodynamic instability on admission or during hospitalization in the case of non-variceal,variceal,and colonic diverticular bleeding,respectively.

Intralesional steroid is beneficial in benign refractory esophageal strictures:A meta-analysis

AIM To analyze the effect of intralesional steroid injections in addition to endoscopic dilation of benign refractory esophageal strictures.METHODS A comprehensive search was performed in three databases from inception to 10 April 2017 to identify trials, comparing the efficacy of endoscopic dilation to dilation combined with intralesional steroid injections. Following the data extraction, meta-analytical calculations were performed on measures of outcome by the randomeffects method of Der Simonian and Laird. Heterogeneity of the studies was tested by Cochrane's Q and I^2 statistics. Risk of quality and bias was assessed by the Newcastle Ottawa Scale and JADAD assessment tools.RESULTS Eleven articles were identified suitable for analyses, involving 343 patients, 235 cases and 229 controls in total. Four studies used crossover design with 121 subjects enrolled. The periodic dilation index(PDI) was comparable in 4 studies, where the pooled result showed a significant improvement of PDI in the steroid group(MD:-1.12 dilation/month, 95% CI:-1.99 to -0.25 P = 0.012; I^2 = 74.4%). The total number of repeat dilations(TNRD) was comparable in 5 studies and showed a non-significant decrease(MD:-1.17, 95%CI:-0.24-0.05, P = 0.057; I^2 = 0), while the dysphagia score(DS) was comparable in 5 studies and did not improve(SMD: 0.35, 95%CI:-0.38, 1.08, P = 0.351; I^2 = 83.98%) after intralesional steroid injection.CONCLUSION Intralesional steroid injection increases the time between endoscopic dilations of benign refractory esophageal strictures. However, its potential role needs further research.

Restoration of energy level in the early phase of acute pediatric pancreatitis

Acute pancreatitis (AP) is a serious inflammatory disease with rising incidence both in the adult and pediatric populations. It has been shown that mitochondrial injury and energy depletion are the earliest intracellular events in the early phase of AP. Moreover, it has been revealed that restoration of intracellular ATP level restores cellular functions and defends the cells from death. We have recently shown in a systematic review and meta-analysis that early enteral feeding is beneficial in adults; however, no reviews are available concerning the effect of early enteral feeding in pediatric AP. In this minireview, our aim was to systematically analyse the literature on the treatmentof acute pediatric pancreatitis. The preferred reporting items for systematic review(PRISMA-P) were followed, and the question was drafted based on participants, intervention, comparison and outcomes: P: patients under the age of twenty-one suffering from acute pancreatitis; I: early enteral nutrition (per os and nasogastric- or nasojejunal tube started within 48 h); C: nil per os therapy; O: length of hospitalization, need for treatment at an intensive care unit, development of severe AP, lung injury (including lung oedema and pleural effusion), white blood cell count and pain score on admission. Altogether, 632 articles (Pub Med: 131; EMBASE: 501) were found. After detailed screening of eligible papers, five of them met inclusion criteria. Only retrospective clinical trials were available. Due to insufficient information from the authors, it was only possible to address length of hospitalization as an outcome of the study. Our mini-meta-analysis showed that early enteral nutrition significantly(SD = 0.806, P = 0.034) decreases length of hospitalization compared with nil per os diet in acute pediatric pancreatitis. In this minireview, we clearly show that early enteral nutrition, started within 24-48 h, is beneficial in acute pediatric pancreatitis. Prospective studies and better presentation of research are crucially needed to achieve a higher level of evidence.