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Shen Z, Yu J, Tang H, Lu B. Closed Loop Duodenal Obstruction Secondary to Pancreatic Carcinoma: A Case Report. Comb Chem High Throughput Screen 2019; 22:280-286. [PMID: 30973103 DOI: 10.2174/1386207322666190411112412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/30/2018] [Accepted: 12/11/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with pancreatic adenocarcinoma may develop into duodenal obstruction during the course of their disease. The diagnosis of obstruction can be generally achieved by means of imaging technologies. Case and Outcome We reported a rare case of pancreatic tumor with duodenal obstruction accompanied by obstructive symptoms, which was finally confirmed by laparotomy. A 68-year-old man was admitted to our department with a 3-day medical history of upper abdominal pain, nausea and vomiting. The diagnosis of duodenal obstruction was established by means of various imagings including computed tomography (CT) scan, gastroscopy and upper gastrointestinal imaging. Upper gastrointestinal imaging and magnetic resonance imaging (MRI) showed extrinsic tumor mass was noted at the second and third portion of the duodenum accompanied by duodenal obstruction and dilatation, respectively. Laparotomy confirmed a tumor mass arising from the head and uncinate process of pancreas, which had invaded the second and third portions of the duodenum and caused closed loop obstruction. A pancreaticoduodenectomy (Whipple procedure) was performed followed by therapeutic trade-off according to intraoperative exploration. Postoperative histopathology revealed pancreatic tumor only infiltrated duodenal wall, while resection margins of pancreas, common bile duct and duodenum were all negative. The patient was cured and discharged home 12 days after surgery. CONCLUSION The present case indicated radical operation in our study appeared to be the first choice treatment for patients with malignant duodenal obstruction.
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Affiliation(s)
- Zhihong Shen
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Jianhua Yu
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Haijun Tang
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Baochun Lu
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
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Chao HC. Update on endoscopic management of gastric outlet obstruction in children. World J Gastrointest Endosc 2016; 8:635-645. [PMID: 27803770 PMCID: PMC5067470 DOI: 10.4253/wjge.v8.i18.635] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/18/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.
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Miyazaki Y, Takiguchi S, Takahashi T, Kurokawa Y, Makino T, Yamasaki M, Nakajima K, Mori M, Doki Y. Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence. World J Gastrointest Endosc 2016; 8:165-172. [PMID: 26862366 PMCID: PMC4734975 DOI: 10.4253/wjge.v8.i3.165] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/02/2015] [Accepted: 12/14/2015] [Indexed: 02/05/2023] Open
Abstract
Malignant gastric outlet obstruction (GOO) is a common condition that results from locally advanced malignancies in the upper gastrointestinal tract, such as pancreatic, gastric, and other carcinomas. Two types of procedures for malignant GOO, namely, gastrojejunostomy (GJ) with laparotomy or a laparoscopic approach and endoscopic stenting (ES), are currently available. Although numerous previous reports have clarified the benefits and drawbacks of each procedure, whether GJ or ES should be used in patients with GOO that results from gastric cancer who may have a longer life expectancy than patients with other malignancies has not been determined. In this review, which focuses on gastric cancer-induced GOO, we analyzed the two systematic reviews and a meta-analysis that compared GJ and ES and outlined the current status of GOO treatment. We also provide an updated review that includes laparoscopic GJ. Various data from 13 studies in one review and 6 studies in another review were analyzed. Although the main results of the present review indicated that both GJ and ES were efficacious treatments in patients with GOO that resulted from gastric cancer, current evidence suggests that GJ may be the preferable procedure given its good performance status and improved prognosis in gastric cancer patients.
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Tominaga K, Maetani I, Shigoka H, Omuta S, Sato K, Ito S, Saigusa Y, Gomi T, Kohda E. Factors associated with delayed gastric emptying in patients with stent placement for malignant gastric outlet obstruction. Endosc Int Open 2013; 1:17-23. [PMID: 26135508 PMCID: PMC4440376 DOI: 10.1055/s-0033-1359266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/05/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Delayed gastric emptying (DGE) is an important factor in determining the clinical outcome in patients with stent placement for malignant gastric outlet obstruction but the factors associated with DGE remain unclear. The aim of this study was to investigate whether clinicopathologic data could be used to identify the factors for DGE in such patients. PATIENTS AND METHODS A prospective, single-arm, observational clinical study was performed in a referral hospital in Japan. A total of 54 patients with stent placement for malignant gastric outlet obstruction were enrolled. A gastric emptying scintigraphy test was performed 1 week after stent placement. The relationship between DGE and clinicopathologic factors was investigated, and also the relationship between DGE and stent patency time, eating period (when the patient was able to maintain oral intake), and survival time. RESULTS A total of 38.9 % (21 /54) of patients had DGE. The following were identified as independent predictive factors of DGE: opioid use (odds ratio, 5.32; 95 % confidence interval [95 %CI], 1.07 - 26.41; p = 0.04), chemotherapy before stent placement (odds ratio, 8.03; 95 %CI, 1.85 - 34.95; p = 0.006), and smaller stent diameter (odds ratio, 13.59; 95 %CI, 1.72 - 107.41; p = 0.01). No relationship was found between DGE and the level of oral intake, stent patency time, eating period, and survival time. CONCLUSIONS The factors associated with DGE after stent placement include those associated with the patient's tumor as well as factors relating to their treatment, including stenting. The clinical and functional results after stent placement appear to be unrelated to the gastric emptying findings.
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Affiliation(s)
- Kenji Tominaga
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan,Corresponding author: Iruru Maetani, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine,Toho University Ohashi Medical Center,2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515,Japan
| | - Hiroaki Shigoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shigefumi Omuta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koichiro Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Sayo Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoshinori Saigusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tatsuya Gomi
- Department of Radiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Ehiichi Kohda
- Department of Radiology, Toho University Ohashi Medical Center, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve. RECENT FINDINGS Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae. SUMMARY This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.
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Zheng B, Wang X, Ma B, Tian J, Jiang L, Yang K. Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Dig Endosc 2012; 24:71-8. [PMID: 22348830 DOI: 10.1111/j.1443-1661.2011.01186.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of the present study was to analyze endoscopic stenting versus gastrojejunostomy of malignant gastric outlet obstruction (GOO). A systematic review of the literature was undertaken to analyze clinical trials on GOO. Six studies were eligible for analysis (three randomized control trials and three controlled clinical trials). Technical success (OR [95% CI]: 0.10 [0.02, 0.47]; I(2) = 0%; P = 0.003) and minor complications (OR [95% CI]: 0.28 [0.10, 0.83]; I(2) = 49%; P = 0.02). Time to oral intake and length of survival were also shorter in the endoscopic stenting (ES) group. There was no statistically significant difference in clinical success, length of survival, mortality and major complications. The present review demonstrated potentially improved quality of life in the ES group. ES is a safe and effective, minimally invasive and cost-effective option for palliation of malignant gastric outlet obstruction. The present review provides supportive evidence that ES should be considered as the gold standard treatment for malignant GOO.
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Affiliation(s)
- Bobo Zheng
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Kim SY, Jeong HY, Seong JK, Song KS, Jung IS, Kim KS, Yoon BY, Moon HS. An Unusual Case of Duodenal Obstruction due to Metastatic Cervical Cancer. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2012. [DOI: 10.7704/kjhugr.2012.12.2.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seul Young Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kue Seong
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyu Sang Song
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Il Soon Jung
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyu Seop Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Beom Yong Yoon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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Kim YW, Choi CW, Kang DH, Kim HW, Chung CU, Kim DU, Park SB, Park KT, Kim S, Jeung EJ, Bae YM. A double-layered (comvi) self-expandable metal stent for malignant gastroduodenal obstruction: a prospective multicenter study. Dig Dis Sci 2011; 56:2030-6. [PMID: 21264512 DOI: 10.1007/s10620-011-1566-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 01/05/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND A self-expandable metal stent (SEMS) has emerged as an effective palliative treatment for malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. Despite the stent's effectiveness, tumor ingrowth and stent migration remain complications requiring reintervention. The purpose of this study was to evaluate the efficacy and safety of a double-layered SEMS (Comvi). METHODS We performed a prospective multicenter study in two university hospitals and two referral hospitals. In fifty consecutive patients with malignant gastroduodenal obstructions, placement of double-layered SEMS, comprising an outer uncovered stent and an inner covered stent that overlap each other, was performed. Palliation, efficacy, and incidence of complications were evaluated. RESULTS Technical and clinical success was achieved in 100 and 88% of patients, respectively. There were no procedure-related complications. Five patients experienced stent migration (10%). For four of five patients' stent migration occurred within two weeks of stent placement. Stent collapse occurred in five patients after one month. Reintervention for stent migration, collapse, or tumor overgrowth was required for 14 (28%) patients. CONCLUSIONS Endoscopic placement of a double-layered stent is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, considering reintervention, this stent does not seem to add any clear advantage compared with preexisting uncovered stents. Migration, especially within the first two weeks, and stent collapse are still unresolved problems. The device should be fixed or the design modified to reduce these problems.
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Affiliation(s)
- Yong Wuk Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea
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Kim YW, Choi CW, Kang DH, Kim HW, Chung CU, Kim DU, Park SB, Park KT, Kim S, Jeung EJ, Bae YM. A double-layered (comvi) self-expandable metal stent for malignant gastroduodenal obstruction: a prospective multicenter study. Dig Dis Sci 2011. [PMID: 21264512 DOI: 10.1107/s10620-011-1566-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND A self-expandable metal stent (SEMS) has emerged as an effective palliative treatment for malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. Despite the stent's effectiveness, tumor ingrowth and stent migration remain complications requiring reintervention. The purpose of this study was to evaluate the efficacy and safety of a double-layered SEMS (Comvi). METHODS We performed a prospective multicenter study in two university hospitals and two referral hospitals. In fifty consecutive patients with malignant gastroduodenal obstructions, placement of double-layered SEMS, comprising an outer uncovered stent and an inner covered stent that overlap each other, was performed. Palliation, efficacy, and incidence of complications were evaluated. RESULTS Technical and clinical success was achieved in 100 and 88% of patients, respectively. There were no procedure-related complications. Five patients experienced stent migration (10%). For four of five patients' stent migration occurred within two weeks of stent placement. Stent collapse occurred in five patients after one month. Reintervention for stent migration, collapse, or tumor overgrowth was required for 14 (28%) patients. CONCLUSIONS Endoscopic placement of a double-layered stent is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, considering reintervention, this stent does not seem to add any clear advantage compared with preexisting uncovered stents. Migration, especially within the first two weeks, and stent collapse are still unresolved problems. The device should be fixed or the design modified to reduce these problems.
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Affiliation(s)
- Yong Wuk Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea
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Kim ID, Kang DH, Choi CW, Kim HW, Jung WJ, Lee DH, Chung CW, Yoo JJ, Ryu JH. Prevention of covered enteral stent migration in patients with malignant gastric outlet obstruction: a pilot study of anchoring with endoscopic clips. Scand J Gastroenterol 2010; 45:100-5. [PMID: 20030581 DOI: 10.3109/00365520903410554] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Placement of a self-expandable metal stent is a palliative treatment of choice for patients with malignant gastric outlet obstruction (GOO). Although covering an enteral stent with a membrane almost solves the problem of tumor ingrowth, stent migration continues to be a major unresolved problem. Our aim was to evaluate the clinical efficacy of endoscopic clipping for prevention of covered stent migration in the treatment of malignant GOO. MATERIAL AND METHODS A total of 25 consecutive patients with malignant GOO were evaluated prospectively. After deployment of a double-layered combination stent (comprising an outer uncovered stent and an inner covered stent), three endoscopic clips were applied for fixation of the proximal end of the enteral stent to the gastric or duodenal mucosa. RESULTS Technical and clinical success rates were 100% (25/25) and 88% (22/25), respectively. No stent migration was observed in any of the patients. Five patients (20%) experienced complications such as tumor overgrowth and stent compression. CONCLUSION Endoscopic clipping for enteral stent placement seems to be effective for prevention of covered stent migration in patients with malignant GOO.
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Affiliation(s)
- Il Du Kim
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Medical Research Institute, Yangsan, South Korea
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Piesman M, Kozarek RA, Brandabur JJ, Pleskow DK, Chuttani R, Eysselein VE, Silverman WB, Vargo JJ, Waxman I, Catalano MF, Baron TH, Parsons WG, Slivka A, Carr-Locke DL. Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial. Am J Gastroenterol 2009; 104:2404-11. [PMID: 19707192 DOI: 10.1038/ajg.2009.409] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet. METHODS In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement. RESULTS Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients. CONCLUSIONS Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.
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Affiliation(s)
- Michael Piesman
- Endoscopy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc 2009; 24:290-7. [PMID: 19551436 DOI: 10.1007/s00464-009-0577-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 04/24/2009] [Accepted: 05/26/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome. METHOD A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO. RESULTS Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ. CONCLUSION This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.
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