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Early View Article: Online published version of an accepted article before publication in the final form.
Journal Name: International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD)
Type of Article: Original Article
Title: Endoscopic palliative treatment versus surgical bypass in malignant low bileduct obstruction: A systematic review and meta-analysis
Authors: Silvia Lucia Alves de Lima, Fabio Alberto Castillo Bustamante, Eduardo
Guimarães Hourneaux de Moura, Wanderley Bernardo Marques, Everson Luiz de
Almeida Artifon, Dalton Marques Chaves, Tomazo Antonio Prince Franzini, Carlos Kiyoshi
Furuya Junior
doi: To be assigned
Early view version published: April 6, 2015
How to cite the article: Alves de Lima SL, Bustamante FAC, Hourneaux de Moura EG, Marques WB, de Almeida Artifon EL, Chaves DM, Prince Franzini TA, Furuya Junior CK. Endoscopic palliative treatment versus surgical bypass in malignant low bileduct obstruction: A systematic review and meta-analysis. International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD). Forthcoming 2015.
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TYPE OF ARTICLE: Original Article 1
2
TITLE: Endoscopic palliative treatment versus surgical bypass in malignant low 3
bileduct obstruction: A systematic review and meta-analysis 4
5
AUTHORS: 6
Silvia Lucia Alves de Lima1, Fabio Alberto Castillo Bustamante2, Eduardo Guimarães 7
Hourneaux de Moura3, Wanderley Bernardo Marques4, Everson Luiz de Almeida 8
Artifon5, Dalton Marques Chaves6, Tomazo Antonio Prince Franzini7, Carlos Kiyoshi 9
Furuya Junior8 10
11
AFFILIATIONS: 12
1MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 13
Medical School. São Paulo, São Paulo, Brazil. Email ID: [email protected] 14
2MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 15
Medical School. São Paulo, São Paulo, Brazil. Email ID: [email protected] 16
3Head Teacher Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of 17
Sao Paulo Medical School. São Paulo, São Paulo, Brazil. Email ID: 18
4Methodological Adviser Gastrointestinal Endoscopy Unit, Hospital das Clinicas, 20
University of Sao Paulo Medical School. São Paulo, São Paulo, Brazil. Email ID: 21
5MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 23
Medical School. São Paulo, São Paulo, Brazil. Email ID: [email protected] 24
6MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 25
Medical School. São Paulo, São Paulo, Brazil. Email ID: 26
7MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 28
Medical School. São Paulo, São Paulo, Brazil. Email ID: [email protected] 29
8MD Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 30
Medical School. São Paulo, São Paulo, Brazil. Email ID: [email protected] 31
32
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CORRESPONDING AUTHOR DETAILS 33
Fabio Alberto Castillo Bustamante, MD, 34
Gastrointestinal Endoscopy Unit, Hospital das Clinicas, University of Sao Paulo 35
Medical School. São Paulo, São Paulo, Brazil. 36
Adress Av Dr Enéas de carvalho Aguiar 255 andar bloco 03, Postal Code 05403900. 37
Contact Phone Number: 1126616221, Fax Number: 1126616463 38
Contact Email ID: [email protected] 39
40
Short Running Title: Malignant bileduct obstruction metanalysis 41
42
Guarantor of Submission : The corresponding author is the guarantor of 43
submission. 44
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TITLE: Endoscopic palliative treatment versus surgical bypass in malignant low 64
bileduct obstruction: A systematic review and meta-analysis 65
66
ABSTRACT 67
Aims: 68
Despite technological advances, only about 20% of periampullary tumors are found 69
to be resectable at the time of presentation. Biliary tree obstruction and consequent 70
jaundice occur in 70–90% of those patients and has important consequences for a 71
patient’s quality of life. Relief of biliary tree obstruction is the main goal for treatment, 72
and few options for palliative therapy of biliary tree obstruction can be performed, 73
including surgical bypass, percutaneous stenting, and endoscopic stenting. 74
Objective: The aim of the present study is to acquire and analyze data to compare 75
the success of procedures, procedure-related complication, mortality in 30 days, 76
recurrent-jaundice rates in endoscopic, and surgical palliative techniques. 77
78
Methods: 79
Two independent reviewers searched the following electronic databases: Medline, 80
EMBASE, Cochrane, LILACS, BVS, SCOPE, and CINAHL (EBSCO). Inclusion 81
criteria included studies involving patients with distal biliary obstruction due to 82
periampullary tumors who underwent endoscopic therapy or a surgical procedure for 83
palliation. 84
85
Results: 86
No differences were observed for success of procedures; differences were observed 87
with better outcomes for endoscopy therapy with regards to mortality associated with 88
procedure, complication associated with procedure, and mortality in 30 days. Also, 89
differences were observed with better outcomes for surgery therapy for recurrent-90
jaundice. 91
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Conclusion: 96
Endoscopic palliative drainage is associated with a lower rate in complication, 97
mortality associated with procedure, and mortality in 30 days. Recurrent-jaundice 98
analysis demonstrated an overall lower rate in surgical bypass procedures. No 99
differences were found for the success of procedures. 100
101
Keywords: Periampullary Tumors; Bile Duct Cancer; Cholangiocarcinoma, 102
Pancreatic Carcinoma; Endoscopy, Gastrointestinal; Surgical Procedures, Operative. 103
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TITLE: Endoscopic palliative treatment versus surgical bypass in malignant low 127
bileduct obstruction: A systematic review and meta-analysis 128
129
INTRODUCTION 130
Jaundice due to biliary obstruction is usually the main symptom at the time of 131
diagnostic in periampullary cancers. Despite technological advances, only about 132
20% of periampullary tumors are found to be resectable at the time of presentation. 133
Biliary tree obstruction and consequent jaundice occur in 70–90% of those patients 134
and has important consequences for a patient’s quality of life. Because of this dismal 135
natural history, palliation remains the principal management in such patients, and 136
relief of biliary tree obstruction is a prime concern [1, 2]. 137
Few options for palliative therapy of biliary tree obstruction can be performed, 138
including surgical bypass, percutaneous stenting, and endoscopic stenting. Although 139
initial results with surgical bypass demonstrated low rates of recurrent jaundice (2–140
5%), the surgery itself carries an appreciable risk of post-operative morbidity and 141
mortality, up to 24% in some trials [3,4]. Surgical decompression has been 142
advocated in patients who at the time of laparotomy for planned tumor resection are 143
found to have unresectable disease as well as in occasional patients with longer 144
projected survival [5, 6]. Advances in minimally invasive therapy have led to the 145
development of luminal stents whose insertion can relieve jaundice and hence avoid 146
the need for surgery [7, 8, 9]. 147
Early biliary stents came in the form of a plastic prosthesis that was inserted across 148
the obstructing mass to provide drainage of the biliary tree; however, bilioduodenal 149
reflux and food fibers result in stent blockage. Various changes in plastic stent 150
design and adjunctive therapy such as antibiotics have failed to significantly improve 151
their patency [10]. With a wider bore than plastic stents, several studies have shown 152
that they exhibit superior patency to plastic stents [11, 12, 13]. 153
Obstructive jaundice due to malignant distal biliary obstruction can thus be relieved 154
by surgery or endoscopic metal or plastic stents [14, 15]. A number of randomized 155
controlled trials (RCTs) have compared various combinations of these interventions 156
[16, 17]. Endoscopic stents appear to offer a less invasive option, but the many 157
designs and stent types available have made selecting the ideal stent for individual 158
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patients complicated. This paper reviews the outcomes associated with surgery and 159
endoscopic therapies. 160
Objectives 161
The aim of the present study is to acquire and analyze data to compare success of 162
procedure, procedure-related complication, mortality in 30 days, and recurrent-163
jaundice rates in endoscopic surgical procedures in patients with distal biliary 164
obstruction due to periampullary tumors (i.e., pancreatic neoplasms or low bile duct 165
carcinoma). 166
167
MATERIALS AND METHODS 168
Protocol and Registration 169
PROSPERO 2015 CRD42015017792 [18] 170
Guidelines http://www.prisma-statement.org/statement.htm 171
Elegibility Criteria 172
a) Types of studies – Randomized clinical trials, controlled clinical trial, and cohort 173
studies. 174
b) Types of participants – Patients with distal biliary obstruction due to periampullary 175
tumors (i.e., pancreatic neoplasms or low bile duct carcinoma). 176
c) Types of intervention – Comparison between endoscopic palliative stents and 177
surgical palliative procedures. 178
d) Types of outcome measures – The main outcome measures were the following: 179
success of procedure, procedure-related complication, mortality in 30 days, and 180
recurrent-jaundice rates. 181
In this literature search, we do not limit ourselves by year of publication or by 182
language. 183
Information sources include MEDLINE as well as the Cochrane Controlled Trials 184
Register, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, Research 185
website BVS, and SCOPE. 186
Search 187
Medline: 188
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P: “(Periampullary Tumors OR Biliary Tract Neoplasms OR Biliary Tract Cancer OR 189
Biliary tract tumors OR Bile Duct Cancer OR Pancreatic Neoplasms OR 190
Cholangiocarcinoma OR Pancreatic Carcinoma) AND 191
I: (Endoscopy OR Endoscopy, Gastrointestinal) AND 192
C: (Surgery OR Surgical Procedures, Operative)”. 193
Embase: 194
P: Pancreatic neoplasms OR bileduct neoplasms AND 195
I: endoscopy AND 196
C: surgery AND 197
('clinical trial' OR 'controlled study' OR 'major clinical study' OR 'prospective study' 198
OR 'retrospective study'))”. 199
Cochrane, LILACS, Scopus and CINAHL: 200
P: pancreatic neoplasms OR bileduct neoplasms AND 201
I: endoscopy AND 202
C: surgery 203
Study Selection 204
Eligibility assessment was performed independently in an unblinded, standardized 205
manner by 2 reviewers. Assessment included a thorough reading of the abstract to 206
identify studies that compare endoscopic with surgical techniques. Studies selected 207
were read in their entirety and excluded according criteria JADAD [19], 208
NEWCASTLE OTTAWA [20] and Mehodology Check List SIGN [21]. Studies that did 209
not report the results in absolute numbers and those not written in English, Spanish, 210
or Portuguese were excluded. Disagreements between reviewers were resolved by 211
consensus. 212
Data Collection Process and Items 213
We extracted data by a detailed reading of the results of each study. This included 214
information on the success of the procedure, procedure-related complication, 215
mortality in 30 days, and recurrent-jaundice rates. We only included absolute 216
numbers reported in the text of the article or with the analysis of graphs. We 217
excluded an article for not reporting the results in absolute numbers. One review 218
author extracted the following data from included studies, and the second author 219
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checked the extracted data. Disagreements were resolved by discussion between 220
the two reviewers; we did not contact authors for further information. 221
Data items 222
The following information was extracted from each included study: Characteristics of 223
population (type and location of tumors); type of intervention, considering different 224
modalities of techniques in endoscopic treatment (plastic stents, metallic stents, 225
covered or uncovered stents) versus surgical approach (hepaticojejunostomy, 226
cholecistojejunostomy, choledocojejunostomy and gastrojejunostomy associated); 227
type of outcome measure including complications, success of procedure, morbidity, 228
mortality, survival in 30 days, recurrent-jaundice, and hospitalization rates. 229
Risk of Bias In Individual Studies 230
Since both cohort and randomized studies were included, the risk of bias in 231
individual studies was assessed using the Newcastle-Ottawa Quality Assessment for 232
cohort studies [20] and JADAD Scale for randomized trials [19] as well as the 233
Mehodology Check List: SIGN for both [21,22]. 234
We extracted data into a table of all studies with the identification of all potential bias 235
of each study. Then, different factors were identified as individual generators of 236
biases, including age, comorbidities, techniques used, prevalence, and experience 237
(see Table 2). 238
Summary Measures 239
Individual analysis for each study included the following: experiment events rate 240
(EER), control event rate (CER), number needed to treat (NNT), and absolute risk 241
(ARR). 242
Synthesis of Results 243
We performed a meta-analysis with the software RevMan5 [23] using the following 244
characteristics: dichotomous data type, statistical method of Mantel-Haenszel, fixed 245
effect model analysis, effect measure risk difference, study confidence interval 95%, 246
total confidence interval 95%, and year of study. 247
Risk of bias across studies . 248
To identify true heterogeneity and cause for publication bias between studies, we 249
conducted both a graphic funnel plot and a I2 analysis. We noted a value of I2 250
greater than 50% as having high heterogeneity. If the study was outside the funnel 251
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plot it was regarded as publication bias, but if it was inside the funnel plot it was 252
considered as having true heterogeneity. 253
254
RESULTS 255
Study Selection 256
We identified 8238 studies through MEDLINE, We identified 1941 studies through 257
COCHRANE, LILACS, SCOPUS, and CINAHL. Eliminating repeated studies, we 258
found 9179 studies in total. We excluded studies that did not have information about 259
periampullary cancers. We chose 8 studies that we reviewed with JADAD [19], 260
NEWCASTLE OTTAWA [20], and the Mehodology Check List: Cohort and Clinical 261
Trial studies SIGN [21]. We excluded a study that was written in French. We 262
included 7 studies for qualitative analysis and 5 studies for quantitative analysis (see 263
fig 1). 264
Study Characteristics 265
The characteristics of the studies are summarized in Table 3. Table 3 describes the 266
oncologic diagnosis analyzed, the number of interventions for each treatment group, 267
and the report in absolute numbers for each outcome of interest extracted. The 268
survival and hospital stay was expressed in mean without standard error, was no 269
topic under analysis. (See Table 1). 270
Risk of Bias Within Studies 271
We identify biases selected for qualitative analysis studies and evaluate them 272
according criteria from the JADAD, Mehodology Check List: SIGN, and 273
NEWCASTLE OTTAWA [19, 20, 21] (see Table 2). 274
Summary Measures 275
Individual analysis for each study included the following: experiment events rate 276
(EER), control event rate (CER), number needed to treat (NNT), and absolute risk 277
(ARR) (see Annex 1). 278
Results of Individual Studies and Synthesis of Resu lts 279
Procedure Success 280
Fig 2. Risk Difference in procedure success. 281
Procedure success: five clinical trial reported procedure success, and the 282
heterogeneity test indicated a χ2 of 4.09 and a I2 of 2%, demonstrating low 283
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heterogeneity. The fixed-effects model was adopted, and the RD was 0.02 (95 % CI: 284
-0.04, 0.07) (Fig. 2). Analysis of the pooled data revealed no statistically significant 285
differences in procedure success between the two therapies. 286
Mortality associated with procedure 287
Fig 3a. Risk difference in mortality associated with procedure for endoscopy and 288
surgery therapies. 289
Mortality associated with procedure: two clinical trials reported mortality associated 290
with procedure, and the heterogeneity test indicated a χ2 of 2.57 and a I2 of 61%, 291
demonstrating high heterogeneity. The fixed-effects model was adopted, and the risk 292
difference was -0.10 (95 % CI: -0.16, –0.03) (Fig. 3a). Analysis of the pooled data 293
revealed differences in mortality associated with procedure with significant risk of 294
bias. The funnel plot analysis identified true heterogeneity, and by consensus of 295
reviewers we opted to perform the meta-analysis using the risk ratio. 296
Fig 3b. Risk ratio in mortality associated with procedure for endoscopy and surgery 297
therapies. 298
Mortality associated with procedure: two clinical trials reported mortality associated 299
with procedure; the heterogeneity test was not applicable. The fixed-effects model 300
was adopted, and the risk ratio was 0.21 (95 % CI: -0.16, –0.03) (Fig. 3a). Analysis 301
of the pooled data revealed differences in mortality associated with procedure that 302
favored endoscopy therapy, with potential bias in this statement. 303
Mortality 30 Days 304
(Fig. 4) Risk Difference in mortality 30 days. 305
Mortality at 30 days: Five clinical trials reported mortality at 30 days; the 306
heterogeneity test indicated a χ2 of 1.44 and a I2 of 0%, demonstrating 307
homogeneity. The fixed-effects model was adopted, and the RD was -0.07 (95 % CI: 308
-0.13, 0.00) (Fig. 2). Analysis of the pooled data revealed statistically significant 309
differences in mortality at 30 days between the two therapies and favors endoscopy 310
therapy. 311
Complication associated with procedure 312
Fig 5a. Risk difference in complication associated with procedure for endoscopy and 313
surgery therapies. 314
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Complication associated with procedure: five clinical trials reported complication 315
associated with procedure; the heterogeneity test indicated a χ2 of 12.10 and a I2 of 316
67%, demonstrating high heterogeneity. The fixed-effects model was adopted, and 317
the RD was -0.19 (95 % CI: -0.28, –0.09) (Fig. 5a). Analysis of the pooled data 318
revealed differences mortality associated with procedure, with potential bias in this 319
statement. In the funnel plot analysis, the study Andersen (1999) was identified as a 320
source of heterogeneity for publication bias. By consensus of reviewers, we opted to 321
withdraw this work from the meta-analysis complication associated with procedure 322
(Fig 5b). 323
Fig 5b. Risk difference in complication associated with procedure for endoscopy and 324
surgery therapies. 325
Complication associated with procedure for endoscopy and surgery therapies: three 326
studies reported complication associated with procedure; the heterogeneity test 327
indicated a χ2 of 3.50 and an I2 of 14%, demonstrating low heterogeneity. The fixed-328
effects model was adopted, and the RD was -0.24 (95 % CI: -0.34, –0.24) (Fig. 5b). 329
Analysis of the pooled data revealed statistically significant differences in 330
complication associated with procedure and showed better outcomes for endoscopy 331
therapy. 332
Recurrent-Jaundice 333
(Fig. 6a) Risk difference in Recurrent-Jaundice 334
Recurrent-Jaundice: four clinical trials reported Recurrent-Jaundice; the 335
heterogeneity test indicated a χ2 of 22.53 and an I2 of 87%, demonstrating high 336
heterogeneity. The fixed-effects model was adopted, and the RD was 0.25 (95 % CI: 337
0.18, 0.32) (Fig. 6a). Analysis of the pooled data revealed differences for Recurrent-338
Jaundice with significant risk of bias in does this affirmation. In the funnel plot 339
analysis, the study Andersen (1989) was identified as a source of heterogeneity for 340
publication bias. By consensus of reviewers, we opted to withdraw this work from the 341
meta-analysis of Recurrent-Jaundice (Fig 6b). 342
Fig 6b. Risk difference in Recurrent-Jaundice for endoscopy and surgery therapies. 343
Recurrent-Jaundice for endoscopy and surgery therapies: three clinical trials 344
reported Recurrent-Jaundice; the heterogeneity test indicated a χ2 of 1.47 and an I2 345
of 0%, demonstrating homogeneity. The fixed-effects model was adopted, and the 346
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RD was 0.30 (95 % CI: 0.22, 0.38) (Fig. 6b). Analysis of the pooled data revealed 347
statistically significant differences for Recurrent-Jaundice and showed better 348
outcomes for surgery therapy. 349
Risk of Bias Across Studies 350
Although the results of success of the procedure were homogeneous between the 351
studies, and no difference was found between the procedures in clinical trials, there 352
is substantial risk of bias because the concept of success is different for each study. 353
Although all are based on a percentage of reduction of billirubin, the percentages 354
that determined a successful procedure were different. 355
Mortality at 30 days was homogeneous between the studies, and statistically 356
significant differences were found between the two therapies that favored endoscopy 357
therapy. We believe this result is one of the most solid because it was exposed in all 358
studies in absolute numbers and because the concept of death is unlikely subject to 359
interpretation bias. 360
With regard to complication associated with procedure, Andersen (1999) was 361
identified as a source of heterogeneity for publication bias. Excluding this study, we 362
analyzed four studies demonstrating low heterogeneity and found statistically 363
significant differences (with low probability of bias) in complication associated with 364
procedure that showed better outcomes for endoscopy therapy. 365
With regard to Recurrent-Jaundice, Andersen (1999) was identified as a source of 366
heterogeneity for publication bias. Excluding this study, we analyzed four studies 367
demonstrating homogeneity and revealed statistically significant differences (with low 368
probability of bias) in Recurrent-Jaundice analysis that showed better outcomes for 369
surgery therapy. 370
371
DISCUSSION 372
Summary of Evidence 373
About 70% of patients with periampullary tumors have evidence of obstructive 374
jaundice at the time of presentation. Therefore, the main goal of palliative therapy in 375
those patients is to resolve the biliary obstruction. Five randomized controlled trials 376
comparing the outcomes of endoscopic stent placement versus surgical bypass for 377
palliation therapy was analyzed. 378
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No statistically significant differences were found in procedure success between the 379
two therapies. Differences were found between mortality associated with procedure 380
that favored the endoscopy therapy. There was significant risk of bias in this 381
affirmation, and the risk ratio was 0.21. Statistically significant differences (NNT 14) 382
in mortality at 30 days between the two therapies favors endoscopy therapy. This is 383
perhaps the most striking result unidentified in previous reviews. Also, statistically 384
significant differences (NNT 4) in complication associated with procedure between 385
the two therapies favors endoscopy therapy. Finally, statistically significant 386
differences (NNH 3) were found for Recurrent-Jaundice and showed better 387
outcomes for surgery therapy. 388
389
LIMITATIONS 390
Several limitations of the present study need to be considered. The characteristics of 391
patients were not comparable in some studies. Although the studies were 392
homogeneous in age, some studies had different average ages, which may lead to a 393
significant bias in the results. Several endoscopic therapies including plastic stent 394
and metallic stent (covered or uncovered) were used, and may be bias generator. 395
The type of operation used was also different in all studies and may cause some 396
biases. Finally, publication bias might exist when including published studies 397
because positive results are more likely to be published than negative results. 398
399
CONCLUSION 400
Endoscopic palliative drainage is associated with a lower rate of complication as well 401
as mortality associated with procedure and mortality within 30 days. Recurrent-402
jaundice analysis demonstrated an overall lower rate in surgical bypass procedures. 403
404
CONFLICT OF INTEREST 405
Declare any financial interest or any conflict of interest exists. 406
407
408
409
410
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AUTHOR’S CONTRIBUTIONS 411
Silvia Lucia Alves de Lima, 412
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 413
data 414
Group 2 - Drafting the article, Critical revision of the article 415
Group 3 - Final approval of the version to be published 416
Fabio Alberto Castillo Bustamante, 417
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 418
data 419
Group 2 - Drafting the article, Critical revision of the article 420
Group 3 - Final approval of the version to be published 421
Eduardo Guimarães Hourneaux de Moura, 422
Group 1 - Conception and design, Acquisition of data, Analysis and interpretation of 423
data 424
Group 2 - Drafting the article, Critical revision of the article 425
Group 3 - Final approval of the version to be published 426
Wanderley Bernardo Marques, 427
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 428
data 429
Group 2 - Drafting the article, Critical revision of the article 430
Group 3 - Final approval of the version to be published 431
Everson Luiz de Almeida Artifon, 432
Group 3 - Final approval of the version to be published 433
Dalton Marques Chaves, 434
Group 3 - Final approval of the version to be published 435
Tomazo Antonio Prince Franzini, 436
Group 3 - Final approval of the version to be published 437
Carlos Kiyoshi Furuya Junior, 438
Group 3 - Final approval of the version to be published 439
440
ACKNOWLEDGEMENTS 441
NIL 442
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71. 531
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TABLES 538
Table 1: Study Characteristics. 539
540
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Table 2: Risk of blas within studies. 551
552
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FIGURE LEGENDS 564
Figure 1: Flow Diagram. 565
Figure 2: Risk Difference in procedure success. 566
Figure 3: (a) Risk difference in mortality associated with procedure for endoscopy 567
and surgery therapies. (b) Risk ratio in mortality associated with procedure for 568
endoscopy and surgery therapies. 569
Figure 4: Risk Difference in mortality 30 days. 570
Figure 5: (a) Risk difference in complication associated with procedure for 571
endoscopy and surgery therapies. (b) Risk difference in complication associated with 572
procedure for endoscopy and surgery therapies. 573
Figure 6: (a) Risk difference in Recurrent-Jaundice. (b) Risk difference in Recurrent-574
Jaundice for endoscopy and surgery therapies. 575
576
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579
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FIGURES 596
597
Figure 1: Flow Diagram. 598
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600
Figure 2: Risk Difference in procedure success. 601
602
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a 612 613 b 614
b 615
Figure 3: (a) Risk difference in mortality associated with procedure for endoscopy 616
and surgery therapies. (b) Risk ratio in mortality associated with procedure for 617
endoscopy and surgery therapies. 618
619
620
Figure 4: Risk Difference in mortality 30 days. 621
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a 622
623
b 624
Figure 5: (a) Risk difference in complication associated with procedure for 625
endoscopy and surgery therapies. (b) Risk difference in complication associated with 626
procedure for endoscopy and surgery therapies. 627
628
629
630
631
632
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a 633
b 634
Figure 6: (a) Risk difference in Recurrent-Jaundice. (b) Risk difference in Recurrent-635
Jaundice for endoscopy and surgery therapies. 636
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Annex 1: 653
654