Antibiotic prophylaxis to prevent complications in endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The prophylactic use of antibiotics in endoscopic retrograde cholangiopancreatography (ERCP) is still controversial.

AIM

To assess whether antibiotic prophylaxis reduces the rates of complications in patients undergoing elective ERCP.

METHODS

This systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A comprehensive search of multiple electronic databases was performed. Only randomized controlled trials were included. The outcomes analyzed included bacteremia, cholangitis, sepsis, pancreatitis, and mortality. The risk of bias was assessed by the Cochrane revised Risk-of-Bias tool for randomized controlled trials. The quality of evidence was assessed by the Grading of Recommendation Assessment, Development, and Evaluation. Meta-analysis was performed using the Review Manager 5.4 software.

RESULTS

Ten randomized controlled trials with a total of 1757 patients that compared the use of antibiotic and non-antibiotic prophylaxis in patients undergoing elective ERCP were included. There was no significant difference between groups regarding incidence of cholangitis after ERCP [risk difference (RD) = -0.02, 95% confidence interval (CI): -0.05, 0.02, P = 0.32], cholangitis in patients with suspected biliary obstruction (RD = 0.02, 95%CI: -0.08 to 0.13, P = 0.66), cholangitis on intravenous antibiotic prophylaxis (RD = -0.02, 95%CI: -0.05 to 0.01, P = 0.25), septicemia (RD = -0.02, 95%CI: -0.06 to 0.01, P = 0.25), pancreatitis (RD = -0.02, 95%CI: -0.06 to 0.01, P = 0.19), and all-cause mortality (RD = 0.00, 95%CI: -0.01 to 0.01, P = 0.71]. However, the antibiotic prophylaxis group presented a 7% risk reduction in the incidence of bacteremia (RD= -0.07, 95%CI: -0.14 to -0.01, P = 0.03).

CONCLUSION

The prophylactic use of antibiotics in patients undergoing elective ERCP reduces the risk of bacteremia but does not appear to have an impact on the rates of cholangitis, septicemia, pancreatitis, and mortality.

Efficacy and Patient Tolerability of Split-Dose Sodium Picosulfate/Magnesium Citrate (SPMC) Oral Solution Compared to the Polyethylene Glycol (PEG) Solution for Bowel Preparation in Outpatient Colonoscopy: An Evidence-Based Review

BACKGROUND

Colonoscopy is the gold standard exam for evaluation of colonic abnormalities and for screening and surveillance for colorectal cancer. However, the efficacy of colonoscopy is dependent on the quality of the pre-colonoscopy bowel preparation. Polyethylene glycol (PEG) and sodium picosulfate/magnesium citrate (SPMC) have emerged as two of the most commonly used bowel preparation agents. We conducted an evidence-based review of current evidence to further investigate the efficacy and patient tolerability of split-dose SPMC oral solution compared to PEG solution for colonoscopy bowel preparation.

METHODS

A systematic search was performed using Pubmed (MEDLINE), Web of Science, EMBASE, and Cochran Central Register of Controlled Trials databases. All studies on split-dose bowel preparation with SPMC and PEG were reviewed. Relevant studies regarding colonoscopy and bowel preparations were also included. Randomized controlled trials were prioritized due to the high quality of evidence.

RESULTS

Eight randomized controlled trials were included. Split-dose SPMC and PEG were associated with similar results for adequacy of bowel preparation. Split-dose SPMC was associated with increased patient tolerability and compliance.

CONCLUSION

Split-dose SPMC and PEG are both adequate and safe for bowel preparation for outpatient colonoscopy, with split-dose SPMC being more tolerable for patients. Additional RCTs comparing these and other bowel preparation solutions are necessary to further investigate quality of bowel preparation, patient preference, and cost-effectiveness of the various options.

THE EFFICACY OF THE DIFFERENT ENDOSCOPIC TREATMENTS VERSUS SHAM, PHARMACOLOGIC OR SURGICAL METHODS FOR CHRONIC GASTROESOPHAGEAL REFLUX DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Endoscopic antireflux treatments for gastroesophageal reflux disease (GERD) are still evolving, and most of the published studies address symptom relief in the short-term. Objective - We aimed to perform a systematic review and meta-analysis focused on evaluating the efficacy of the different endoscopic procedures.

METHODS

Search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane, SciELO, and EMBASE for patients with chronic GERD (>6 months), over 18 years old and available follow up of at least 3 months. The main outcome was to evaluate the efficacy of the different endoscopic treatments compared to sham, pharmacological or surgical treatment. Efficacy was measured by different subjective and objective outcomes.

RESULTS

We analyzed data from 16 RCT, totaling 1085 patients. The efficacy of endoscopic treatments compared to sham and proton pump inhibitors (PPIs) treatment showed a significant difference up to 6 months in favor of endoscopy with no heterogeneity (P<0.00001) (I2: 0%). The subgroup analysis showed a statistically significant difference up to 6 months in favor of endoscopy: endoscopy vs PPI (P<0.00001) (I2: 39%). Endoscopy vs sham (P<0.00001) (I2: 0%). Most subjective and objective outcomes were statistically significant in favor of endoscopy up to 6 and 12 months follow up.

CONCLUSION

This systematic review and meta-analysis shows a good short-term efficacy in favor of endoscopic procedures when comparing them to a sham and pharmacological or surgical treatment. Data on long-term follow up is lacking and this should be explored in future studies.

ENDOSCOPIC ULTRASOUND IN THE EVALUATION OF UPPER SUBEPITHELIAL LESIONS

BACKGROUND

Endoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract.

OBJECTIVE

The present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions.

METHODS

Retrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions.

RESULTS

Lesions of the fourth layer were more common in the stomach (63.72%) than in the esophagus (44.68%) and duodenum (29.03%). In stomach, 81.1% of the lesions ≥2 cm, and 96.5% ≥3 cm, were from the fourth layer. Endosonographic signs that could be related to malignant behavior, such as irregular borders, echogenic foci, cystic spaces and/or size greater than 3 cm were identified in 34 (15.81%) lesions at the first endoscopic ultrasound evaluation. Endoscopic ultrasound-fine needle aspiration did the diagnosis in 21 (61.76%) patients who were submitted a puncture. Three (12.0%) lesions of 25 who were submitted to regular endoscopic ultrasound surveillance increased the size.

CONCLUSION

Stomach is the organ most affected with subepithelial lesions of the gastrointestinal tract and the fourth layer was the most common layer of origin. More than 80% of gastric subepithelial lesions from the fourth layer are ≥2 cm. Endoscopic ultrasound evaluation of subepithelial lesions has been very important for stratification into risk groups and to determine the best management.

Endoscopic sleeve gastroplasty with argon plasma coagulation: A novel technique

OBJECTIVE

The endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure in which the anterior and posterior aspects of the greater curvature are stitched endoscopically, producing a sleeve-like anatomy mimicking that in a sleeve gastrectomy. However, suture dehiscence and enlargement of the stomach within months of the procedure have been observed. Argon plasma coagulation (APC) is widely used in gastrointestinal endoscopy and is able to induce scarring and fibrosis. We coupled ESG with APC to evaluate its potential to improve durability.

METHODS

A 46-year-old woman with obesity presented for ESG. Her pre-procedure weight was 117 kg with a body mass index (BMI) of 41.4 kg/m2 . After each plication was complete, APC (60 W, argon flow rate 1.2 L/min) was used to ablate the mucosal surface of the exposed plicated mucosa. APC was applied until the mucosal color was dark brown, indicating adequate and successful mucosal and submucosal ablation.

RESULTS

The procedure was successful, and the patient recovered without peri- or post-operative complications. The procedure time was 47 minutes. A total of seven sutures were used. At 6-month follow-up the patient had lost 17 kg (37.5 lbs), equivalent to 14.5% total weight loss and had a BMI of 35.4 kg/m2 . Endoscopic follow-up at 6 months revealed enhanced fibrosis along the plications, resulting in a superior, sleeve-like lumen.

CONCLUSIONS

The combination of ESG with APC may act synergistically to reduce weight without adding significant procedure time. Further investigation is needed to determine whether it should be widely recommended.

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections - review and new proposed classification

Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions - such as disruptions and strictures - are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.

Subepithelial rectal gastrointestinal stromal tumor - the use of endoscopic ultrasound-guided fine needle aspiration to establish a definitive cytological diagnosis: a case report

BACKGROUND

Gastrointestinal stromal tumors are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The stomach is the most common location to be affected, and the rectum one of the rarest, but the whole gastrointestinal tract remains susceptible. Gastrointestinal stromal tumors account for only 0.1% of rectal tumors. Currently, endoscopic ultrasound plays an essential role in the diagnostic process of gastrointestinal stromal tumors, especially when the affected sites have a worse outcome and higher morbidity rates.

CASE PRESENTATION

We describe the case of a 68-year-old white Japanese man with a history of long-term mild rectal pain and tenesmus. A digital rectal examination revealed a right palpable solid mass ranging from 3 to 7 cm from his anal verge. A colonoscopy was performed and showed a 5 cm elevated lesion covered by normal mucosa, located 4 cm above the pectineal line. Endoscopic ultrasound confirmed the diagnosis of a homogeneous hypoechoic mass with areas of necrosis as a rectal subepithelial lesion originating at the fourth layer (muscularis propria). He then underwent endoscopic ultrasound-guided fine needle aspiration of the lesion, followed by cytological and immunohistochemistry evaluation. The evaluation showed spindle and epithelioid cells of variable sizes, in fascicles separated by stroma, which reacted firmly and consistently to CD117/c-kit and CD34, and negative to desmin and S-100 protein. There was weak staining for nuclear Ki-67 in the tumor cells. A diagnosis of rectal gastrointestinal stromal tumor was confirmed. After a multidisciplinary meeting, an abdominoperineal resection of his rectum was performed. The pathology of the specimen confirmed the diagnosis of rectal gastrointestinal stromal tumor. He is now asymptomatic after 3 months' follow-up and is on adjuvant therapy with a tyrosine-kinase inhibitor.

CONCLUSIONS

Gastrointestinal stromal tumors are rare tumors, and among the variety of primary location sites, the rectum is one of the rarest. The localization of this type of tumor has worse outcomes and higher morbidity rates. We report this rare case to emphasize the need for precise diagnosis and the important role of endoscopic ultrasound-guided fine needle aspiration in such situations.

Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07‒0.51; p = 0.009 I² = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06‒0.33; p < 0.0001; I² = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05‒0.16; p < 0.0001; I² = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 ‒ -2,43; p < 0.00001; I² = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 ‒ -0.11; p < 0.00001; I² = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01‒0.15; p = 0.02; I² = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases.

Stent versus Balloon Dilation for the Treatment of Dominant Strictures in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis

BACKGROUND/AIMS

The endoscopic management of primary sclerosing cholangitis (PSC)-associated dominant strictures remains challenging. This systematic review and meta-analysis aimed to compare balloon dilation and stent placement in the treatment of dominant strictures among PSC patients.

METHODS

Literature searches on MEDLINE, EMBASE, Cochrane CENTRAL and Lilacs/Bireme were performed for studies published until December 2020. Measured outcomes included clinical efficacy, stricture recurrence, cumulative recurrencefree rate, transplant rate, 5-year survival rate, and adverse events (i.e., pancreatitis, cholangitis, bleeding, perforation and death).

RESULTS

A total of 5 studies (n=467) were included. Based on pooled analyses, there were no differences in clinical efficacy (risk difference [RD], -0.13; 95% confidence interval [CI], -0.58 to 0.33; I2=93%) or transplant rates (RD, -0.09; 95% CI, -0.19 to 0.01; I2=0%); however, the risk of occurrence of adverse events was lower with balloon dilatation than with stent placement (RD,-0.34; 95% CI, -0.45 to -0.23; I2=61%). Among the types of adverse events reported, only the rates of cholangitis/bacteremia were significantly lower in balloon dilation patients (RD, -0.19; 95% CI, -0.25 to -0.13; I2=51%).

CONCLUSION

Compared to balloon dilation, stent placement for dominant strictures in PSC appeared to have higher complication rates without significant differences in efficacy.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions: A multi-center analysis

BACKGROUND

While endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is considered a preferred technique for tissue sampling for solid lesions, fine needle biopsy (FNB) has recently been developed.

AIM

To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions.

METHODS

A retrospective, multi-center study of EUS-guided tissue sampling using FNA vs FNB needles. Measured outcomes included diagnostic test characteristics (i.e., sensitivity, specificity, accuracy), use of rapid on-site evaluation (ROSE), and adverse events. Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE. A multivariable logistic regression was also performed.

RESULTS

A total of 1168 patients with solid lesions (n = 468 FNA; n = 700 FNB) underwent EUS-guided sampling. Mean age was 65.02 ± 12.13 years. Overall, sensitivity, specificity and accuracy were superior for FNB vs FNA (84.70% vs 74.53%; 99.29% vs 96.62%; and 87.62% vs 81.55%, respectively; P < 0.001). On subgroup analyses, sensitivity, specificity, and accuracy of FNB alone were similar to FNA + ROSE [(81.66% vs 86.45%; P = 0.142), (100% vs 100%; P = 1.00) and (88.40% vs 85.43%; P = 0.320]. There were no difference in diagnostic yield of FNB alone vs FNB + ROSE (P > 0.05). Multivariate analysis showed no significant predictor for better accuracy. On subgroup analyses, FNB was superior to FNA for non-pancreatic lesions; however, there was no difference between the techniques among pancreatic lesions. One adverse event was reported in each group.

CONCLUSION

FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA + ROSE in the diagnosis of non-pancreatic solid lesions. Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.

CASE SUMMARY

A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.

CONCLUSION

APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

Impact of Endoscopic Sleeve Gastroplasty in Non-alcoholic Fatty Liver Disease: a Systematic Review and Meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. Endoscopic sleeve gastroplasty (ESG) has proven to be feasible, safe, and effective in the management of obesity. We performed the first systematic review and meta-analysis evaluating NAFLD and other metabolic parameters 12 months post-ESG. Four observational studies with a total of 175 patients were included. The results showed a significant (p < 0.05) reduction of 4.85 in hepatic steatosis index (95% CI - 6.02, - 3.67), 0.5 in NAFLD fibrosis score (95% CI - 0.80, - 0.19), 6.32 U/l in ALT (95% CI - 9.52, - 3.11), 17.28% in TWL (95% CI - 18.24, - 16.31), 6.31 kg/m2 in BMI (95% CI - 8.11, - 4.52), 47.97% in EWL (95% CI - 49.10, - 46.84), and 0.51% in HbA1c (95% CI - 0.90, - 0.12). ESG improves liver parameters, provides weight loss, and reduces HbA1c levels in patients suffering from NAFLD.

Modifying an Intragastric Balloon for the Treatment of Obesity: a Unique Approach

INTRODUCTION

The use of intragastric balloons (IGB) for the treatment of obesity has been increasing significantly, with data confirming its effectiveness with low complication rates. Adjustable balloons are not widely available for use in all countries, including the USA. In this video, we demonstrate a unique technique in which a conventional nonadjustable balloon is modified to an adjustable balloon to improve weight loss.

METHODS

A 35-year-old woman with a BMI of 36.1 kg/m2 (84.4 kg) who had failed prior medical therapy for obesity presented for IGB placement. After discussion with the patient, including risks and benefits, a conventional IGB modified to a novel adjustable IGB was placed.

RESULTS

In this primary experience, we describe the use of a conventional IGB modified to an adjustable balloon. First, during balloon placement, an initial 500 ml of saline was instilled. At one-month follow-up, the patient only experienced 3.67%TBWL; thus, the balloon was adjusted with the addition of 160 ml of saline through the newly created modification catheter. At a 2-month follow-up, a second adjustment was performed with the addition of 180 ml, for a total of 840 ml. At 4 months, patient experienced 10% TBWL and decreased in BMI by 3.6 kg/m2. No adverse events were reported.

CONCLUSION

The transformation of a nonadjustable balloon into an adjustable balloon is feasible and effective in weight loss. This technique may be an alternative in cases where adjustable balloon is not available. Further studies are warranted to confirm the safety and efficacy of this novel device.