Roux-en-Y versus BillrothⅠreconstruction after distal gastrectomy for gastric cancer:A meta-analysis

AIM: To conduct a meta-analysis to compare Roux-en-Y (R-Y) gastrojejunostomy with gastroduodenal Billroth?I?(B-I) anastomosis after distal gastrectomy (DG) for gastric cancer.METHODS: A literature search was performed to identify studies comparing R-Y with B-I?after DG for gastric cancer from January 1990 to November 2012 in Medline, Embase, Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either ?xed or random effects model. Operative outcomes such as operation time, intraoperative blood loss and postoperative outcomes such as anastomotic leakage and stricture, bile re?ux, remnant gastritis, re?ux esophagitis, dumping symptoms, delayed gastric emptying and hospital stay were the main outcomes assessed. Meta-analyses were performed using RevMan 5.0 software (Cochrane library).RESULTS: Four randomized controlled trials (RCTs) and 9 non-randomized observational clinical studies (OCS) involving 478 and 1402 patients respectively were included. Meta-analysis of RCTs revealed that R-Y reconstruction was associated with a reduced bile re?ux (OR 0.04, 95%CI: 0.01, 0.14; P < 0.00?001) and remnant gastritis (OR 0.43, 95%CI: 0.28, 0.66; P = 0.0001), however needing a longer operation time (WMD 40.02, 95%CI: 13.93, 66.11; P = 0.003). Meta-analysis of OCS also revealed R-Y reconstruction had a lower incidence of bile re?ux (OR 0.21, 95%CI: 0.08, 0.54; P = 0.001), remnant gastritis (OR 0.18, 95%CI: 0.11, 0.29; P < 0.00?001) and re?ux esophagitis (OR 0.48, 95%CI: 0.26, 0.89; P = 0.02). However, this reconstruction method was found to be associated with a longer operation time (WMD 31.30, 95%CI: 12.99, 49.60; P = 0.0008).CONCLUSION: This systematic review point towards some clinical advantages that are rendered by R-Y compared to B-I?reconstruction post DG. However there is a need for further adequately powered, well-designed RCTs comparing the same.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM:To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection(LLR) and open liver resection(OLR) for hepatocellular carcinoma(HCC).METHODS:PubMed(Medline),EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012.Two authors independently assessed the trials for inclusion and extracted the data.Meta-analysis was performed using Review Manager Version 5.0 software(The Cochrane Collaboration,Oxford,United Kingdom).Pooled odds ratios(OR) or weighted mean differences(WMD) with 95%CI were calculated using either fixed effects(Mantel-Haenszel method) or random effects models(DerSimonian and Laird method).Evaluated endpoints were operative outcomes(operation time,intraoperative blood loss,blood transfusion requirement),postoperative outcomes(liver failure,cirrhotic decompensation/ascites,bile leakage,postoperative bleeding,pulmonary complications,intraabdominal abscess,mortality,hospital stay and oncologic outcomes(positive resection margins and tumor recurrence).RESULTS:Fifteen eligible non-randomized studies were identified,out of which,9 high-quality studies involving 550 patients were included,with 234 patients in the LLR group and 316 patients in the OLR group.LLR was associated with significantly lower intraoperative blood loss,based on six studies with 333 patients [WMD:-129.48 mL;95%CI:-224.76-(-34.21) mL;P = 0.008].Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups.The LLR group had lower blood transfusion requirement(OR:0.49;95%CI:0.26-0.91;P = 0.02).While analyzing hospital stay,six studies with 333 patients were included.Patients in the LLR group were found to have shorter hospital stay [WMD:-3.19 d;95%CI:-4.09-(-2.28) d;P < 0.00001] than their OLR counterpart.Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups.The LLR group appeared to have a lower incidence of postoperative ascites(OR:0.32;95%CI:0.16-0.61;P = 0.0006) as compared with OLR patients.Similarly,fewer patients had liver failure in the LLR group than in the OLR group(OR:0.15;95%CI:0.02-0.95;P =0.04).However,no significant differences were found between the two approaches with regards to operation time [WMD:4.69 min;95%CI:-22.62-32 min;P = 0.74],bile leakage(OR:0.55;95%CI:0.10-3.12;P = 0.50),postoperative bleeding(OR:0.54;95%CI:0.20-1.45;P = 0.22),pulmonary complications(OR:0.43;95%CI:0.18-1.04;P = 0.06),intra-abdominal abscesses(OR:0.21;95%CI:0.01-4.53;P = 0.32),mortality(OR:0.46;95%CI:0.14-1.51;P = 0.20),presence of positive resection margins(OR:0.59;95%CI:0.21-1.62;P = 0.31) and tumor recurrence(OR:0.95;95%CI:0.62-1.46;P = 0.81).CONCLUSION:LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence.However,further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

A study on drug utilization and prescription habits of physicians in a government homeopathic hospital in West Bengal, India

Improper prescribing habits and inappropriate drug use lead to serious health and economic consequences. This study was undertaken to evaluate drug utilization services and prescription patterns of homeopathic doctors in a government homeopathic teaching hospital in India. METHODS： No standardized homeopathic drug use indicators are available. The researchers used indicators for health care setting （drug availability）-modified prescribing indicators and patient care indicators, based on World Health Organization＇s core drug use indicators. A cross- sectional, prospective, institutional, observational study of 2-month duration with record analysis was conducted on 600 patients visiting seven different outpatient departments （OPDs） for the first time at Mahesh Bhattacharyya Homeopathic Medical College ＆ Hospital, Howrah, West Bengal, India, using the developed indicators. RESULTS： Overall availability of prescribed drugs was quite satisfactory （92.28%）. Centesimal potencies accounted for the majority of prescriptions （74.76%）. There was a poor record of diagnosis （39.17%） except in the OPDs of Gynecology and Obstetrics （68.48%, P 〈 0.01） and Dermatology （64.58%, P 〈 0.01）. Records of investigational findings and ongoing therapies, if any, were also poor except OPDs of Gynecology and Obstetrics, and Pediatrics. Structure of prescriptions was maintained satisfactorily in all the OPDs. Though tendency of using ＇individualized homeopathy＇ predominated, there also existed the use of ＇polypharmacy＇. Mean consultation time was 5.9 min. Labeling was extremely poor and is an area needing improvement. The prescriptions were highly legible. CONCLUSION： This was a preliminary study, conducted for the first time in homeopathy using newly developed indicators that yield meaningful results. Further studies are necessary in order to evaluate the different factors involved and to plan future interventions to improve the quality of care in healthcare settings.

Modified Da-Cheng-Qi Decoction reduces intra-abdominal hypertension in severe acute pancreatitis： a pilot study

Background Intra-abdominal hypertension （IAH） is a recognized prognostic marker for severity of severe acute pancreatitis （SAP） and has a strong impact on the clinical course of SAP. Previous studies indicate that a Da-Cheng-Qi Decoction （DCQD） is beneficial in the treatment of SAP. The purpose of this study was to evaluate the effect of modified DCQD on IAH in patients with SAP. Methods Between January 2008 and December 2008, 42 patients from the West China Hospital were randomized into either the DCQD or control group （n=21 in each group）. Mortality, intra-abdominal pressure （lAP）, Acute Physiology and Chronic Health Evaluation II （APACHE II） score, C-reactive protein （CRP）, oxygenation index, Balthazar CT score, rate of renal failure, decompression rate, intensive care unit （ICU） transfer rate, and length of hospital stay （LOS） were compared between the two groups. Results Compared to the control group, the modified DCQD treatment significantly decreased lAP （P 〈0.05） and APACHE II （P 〈0.05） scores on days 4-8, CRP on day 8 （P 〈0.01）, renal failure rate （P 〈0.05）, and LOS （P 〈0.05）. The oxygenation index was significantly improved in the DCQD group compared with the control group （P 〈0.05）. No significant differences in the Balthazar CT score, shock rate, ICU transfer rate, or mortality occurred between the two groups. Conclusions The modified DCQD can effectively relieve IAH and decrease LOS for patients with SAP. Larger clinical trials are needed to confirm these findings.

Precision medicine for acute pancreatitis:current status and future opportunities

Acute pancreatitis is a common inflammatory condition affecting the pancreas,predominantly caused by gallstones,alcohol excess,and hypertriglyceridaemia,with severe disease carrying up to 50%mortality.Despite significant research and preclinical promise,no targeted drug treatments exist for the disease and precision medicine approaches are lacking significantly,when compared to other health conditions.Advances in omics applications will facilitate improved preclinical models and target identification as well as biomarker discovery for refined trial design,focusing on risk stratification,subject selection,and outcome determination.Randomised treatment of Acute Pancreatitis with Infliximab:Double-blind,placebo-controlled,multi-centre trial(RAPID-I)is a pioneering trial,currently under way in acute pancreatitis,which may serve as an innovative model for the implementation of precision medicine strategies for acute pancreatitis in the future.