Adverse Events and Device Failures Associated with Pancreatic Stents: A Comprehensive Analysis Using the FDA's MAUDE Database

INTRODUCTION

Pancreatic duct stents (PDS) are widely used for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, there is a paucity of data regarding the adverse events associated with PDS placement. This study aims to investigate the reported adverse events and device failures related to PDS, utilizing the Manufacturer and User Facility Device Experience (MAUDE) database maintained by the U.S. Food and Drug Administration (FDA).

METHODS

Post-marketing surveillance data from January 2013 to December 8, 2023, were extracted from the FDA's MAUDE database to analyze the reports pertaining to the use of commonly used PDS. The primary outcomes of interest were device issues and patient-related adverse events. Statistical analysis was performed using Microsoft Excel 2010, with the calculation of pooled numbers and percentages for each device and patient adverse event.

RESULTS

A total of 579 device issues and 194 patient-related adverse events were identified. Device issues were primarily attributed to stent deformation (n = 72; 12.4%), followed by migration of the device into the pancreatic duct or expulsion out of the duct (n = 60; 10.4%), and stent fracture/breakage (n = 55; 9.4%). Among the patient-reported adverse events, inflammation was the most common (n = 26; 13.4%), followed by reports of stents becoming embedded in tissue (n = 21; 10.8%) and stent occlusion/obstruction (n = 16; 8.2%). The most prevalent device failures associated with Advanix stents were material deformation, with perforation (n = 3, 30%) being the most frequently reported adverse event. Concerning Geenen stents, migration or expulsion of the device (n = 34, 16.9%) constituted the most common device-related adverse events, while inflammation (n = 20, 16.7%) was the most frequently reported patient-related issue. For Zimmon stents, migration or expulsion of the device (n = 22, 8.8%) were the most frequently reported device-related problems, whereas perforation (n = 7, 10.9%) and bleeding (n = 7, 10.9%) were the most frequent patient-related adverse events.

CONCLUSION

Our findings highlight important device and patient adverse events that endoscopists and referring providers should be aware of before considering pancreatic stent placement.

Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia.

METHODS

We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively.

RESULTS

The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux.

CONCLUSION

PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Cold Snare Polypectomy in Small (<10 mm) Pedunculated Colorectal Polyps: A Systematic Review and Meta-analysis

INTRODUCTION

Endoscopic removal techniques for colorectal polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). Although HSP is recommended for pedunculated polyps (PPs) larger than 10 mm, data regarding use of CSP for PPs <10 mm continues to emerge. We aimed to investigate outcomes of these techniques in small (<10 mm) pedunculated colorectal polyps.

METHODS

Multiple databases were searched till June 2022 to identify studies involving the removal of small PPs with CSP and HSP. Random effects model was used to calculate outcomes and 95% CI. Primary outcome was the pooled rate of successful en-bloc resection. Secondary outcomes were immediate and delayed bleeding with CSP and HSP as well as prophylactic and post resection clip placement.

RESULTS

Six studies including 1025 patients (1111 polyps with a mean size 4 to 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of successful en-bloc resection with CSP was 99.7% (CI 99.1-99.9; I2 0%). Pooled immediate and delayed bleeding after CSP was 49.8% (CI 46.8-52.91; I2 98%) and 0% (CI 0.00-0.00; I2 0%), respectively. Delayed bleeding was higher with HSP, relative risk 0.05 (CI 0.01-0.43; I2 0%), P =0.006, whereas immediate bleeding was higher with CSP, relative risk 7.89 (CI 4.36-14.29; I2 0%), P <0.00001. Pooled rates of prophylactic clip placement and post-procedure clip placement (to control immediate bleeding) were 55.3% and 47.2%, respectively. Finally, right colon polyp location significantly correlated with frequency of immediate bleeding.

CONCLUSION

Our analysis shows that CSP is safe and effective for resection of small PPs.

International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process

INTRODUCTION

The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications.

METHODS

Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round.

RESULTS

Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events.

DISCUSSION

Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.

Predicting the risk of early intensive care unit admission for patients hospitalized with acute pancreatitis using supervised machine learning

Background

Acute pancreatitis (AP) is a complex and life-threatening disease. Early recognition of factors predicting morbidity and mortality is crucial. We aimed to develop and validate a pragmatic model to predict the individualized risk of early intensive care unit (ICU) admission for patients with AP.

Methods

The 2019 Nationwide Readmission Database was used to identify patients hospitalized with a primary diagnosis of AP without ICU admission. A matched comparison cohort of AP patients with ICU admission within 7 days of hospitalization was identified from the National Inpatient Sample after 1:N propensity score matching. The least absolute shrinkage and selection operator (LASSO) regression was used to select predictors and develop an ICU acute pancreatitis risk (IAPR) score validated by 10-fold cross-validation.

Results

A total of 1513 patients hospitalized for AP were included. The median age was 50.0 years (interquartile range: 39.0-63.0). The three predictors that were selected included hypoxia (area under the curve [AUC] 0.78), acute kidney injury (AUC 0.72), and cardiac arrhythmia (AUC 0.61). These variables were used to develop a nomogram that displayed excellent discrimination (AUC 0.874) (bootstrap bias-corrected 95% confidence interval 0.824-0.876). There was no evidence of miscalibration (test statistic = 2.88; P = 0.09). For high-risk patients (total score >6 points), the sensitivity was 68.94% and the specificity was 92.66%.

Conclusions

This supervised machine learning-based model can help recognize high-risk AP hospitalizations. Clinicians may use the IAPR score to identify patients with AP at high risk of ICU admission within the first week of hospitalization.

Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum.

METHODS

We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2% values were used to assess the heterogeneity.

RESULTS

A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2=63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2=60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2=24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2=24%).

CONCLUSIONS

The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.

Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). The aim of this study was to compare the safety of these procedures for AC in surgically suboptimal candidates.

METHODS

Six studies compared the 2 groups' early, delayed, and overall adverse events; they also compared length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios (ORs) with a 95% confidence interval (CI).

RESULTS

The 2 groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR, .21; 95% CI, .07-.61; P ≤ .01) and overall (OR, .43; 95% CI, .30-.61; P ≤ .01) adverse events. Patients with EUS-GBD-LAMSs had a shorter hospital stay than PTGBD.

CONCLUSIONS

EUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in nonsurgical candidates with AC.

Per-oral cholangioscopy in patients with primary sclerosing cholangitis: a 12-month follow-up study

Background and study aims Patients with primary sclerosing cholangitis (PSC) have a 9% to 20% lifetime incidence of cholangiocarcinoma (CCA). Per-oral cholangioscopy (POCS) added to endoscopic retrograde cholangiography (ERC) could potentially improve detection of CCA occurrence. We prospectively assessed POCS identification of 12-month CCA incidence in PSC patients undergoing ERC. Patients and methods Consecutive patients with PSC, an indication for ERC, and no prior liver transplantation were enrolled. During the index procedure, POCS preceded planned therapeutic maneuvers. The primary endpoint was ability for POCS visualization with POCS-guided biopsy to identify CCA during 12-month follow-up. Secondary endpoints included ability of ERC/cytology to identify CCA, repeat ERC, liver transplantation, and serious adverse events (SAEs). Results Of 42 patients enrolled, 36 with successful cholangioscope advancement were analyzed. Patients had a mean age 43.5±15.6 years and 61% were male. Three patients diagnosed with CCA had POCS visualization impressions of benign/suspicious/suspicious, and respective POCS-guided biopsy findings of suspicious/positive/suspicious for malignancy at the index procedure. The three CCA cases had ERC visualization impressions of benign/benign/suspicious, and respective cytology findings of atypical/atypical/suspicious for malignancy. No additional patients were diagnosed with CCA during median 11.5-month follow-up. Twenty-three repeat ERCs (5 including POCS) were performed in 14 patients. Five patients had liver transplantation, one after CCA diagnosis and four after benign cytology at the index procedure. Three patients (7.1%) had post-ERC pancreatitis. No SAEs were POCS-related. Conclusions In PSC patients, POCS visualization/biopsy and ERC/cytology each identified three cases of CCA. Some patients had a repeat procedure and none experienced POCS-related SAEs.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data.

METHODS

Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model.

RESULTS

Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P<0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P=0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P=0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P=0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P=0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P=0.16).

DISCUSSION

On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.

Cannulation rates and technical performance evaluation of commericially available single-use duodenoscopes for endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis

BACKGROUND

Single use duodenoscopes were developed to reduce the risk of infection transmission from contaminated reusable duodenoscopes. To this end, we examined various biliary interventions using single use duodenoscopes in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Medline, Embase, Scopus, and Cochrane databases were searched from inception through Aug 2022 to identify studies reporting on the performance of single use duodenoscopes for ERCP.

RESULTS

Seven articles were included in the final analysis that included 642 patients (318 males). The Exalt Model D duodenoscope was used in most cases (88.8%) followed by the aScope Duodeno (11.2%) for ERCP. Most ERCPs had a complexity grade of 2 (n = 303) and 3 (n = 198). The pooled cumulative rate of successful cannulation was 95% (95% Confidence Interval (CI): 93-96%, I2=0%, P = 0.46). Sphincterotomy was successfully performed in all cases. The pooled cumulative rate of PEP was 2% (95% CI: 0.4-3.4%, I2=0%, P = 0.80). The pooled cumulative rate of total adverse events was 7% (95% CI: 4-10%, I2=47%, P = 0.08).

CONCLUSIONS

The results of this systematic review and meta-analysis show that single use duodenoscopes are associated with high cannulation rates, technical performance, and safety profile.

Efficacy of cap-assisted endoscopy for the visualization of the major duodenal papilla: a systematic review and meta-analysis

BACKGROUND AND AIMS

The current standard of practice is to use a duodenoscope for the evaluation of the major duodenal papilla (MDP). Recently, cap-assisted endoscopy (CAE), which uses a transparent cap at the tip of a standard front-viewing endoscope, has emerged as an alternative.

METHODS

A systematic literature search was performed in several databases from inception to January 2023 to identify studies evaluating the efficacy of CAE for the evaluation of the MDP.

RESULTS

Nine studies including 806 patients met our inclusion criteria. The pooled rate of technical success for CAE was 93.2% (95% confidence interval, 85.6-96.9; I2 = 84.6%). A subgroup analysis comparing CAE with a standard endoscope showed higher odds for the evaluation of the MDP with CAE (but not a duodenoscope, which was better than CAE) with an odds ratio of 57.294 (95% confidence interval, 17.767-184.755; I2 = 45.303%).

CONCLUSIONS

CAE offers a significant advantage with high rates of complete MDP evaluation compared with standard forward-viewing endoscopy. However, CAE is associated with lower rates of success when compared with side-viewing endoscopes.

Cold Versus Hot Endoscopic Mucosal Resection for Sessile Serrated Colorectal Polyps ≥10 mm: A Systematic Review and Meta-analysis

INTRODUCTION

We performed a systematic review and meta-analysis studying the efficacy and safety of cold versus hot endoscopic mucosal resection (EMR) for resection of sessile serrated polyps (SSPs) ≥10 mm.

METHODS

Multiple databases were searched until January 2023 for studies reporting outcomes of cold versus hot EMR for SSPs ≥10 mm. The primary outcome was the residual SSP rate. Secondary outcomes included technical success rate, R0 resection rate, and adverse events. We used standard meta-analysis methods using the random-effects model, and I2% was used to assess heterogeneity.

RESULTS

Thirteen studies were included in the final analysis. In all, 1896 SSPs were included with a mean polyp size of 23.7 mm (range, 15.9 to 33). A total of 1452 SSPs were followed up for a median follow-up duration of 15.3 months (range, 6 to 37). The pooled residual SSP rate for cold EMR was 4.5% (95% CI: 1.0-17.4), and 5.1% (95% CI: 2.4-10.4) for hot EMR (P=0.9). The pooled rates of technical success, R0 resection, immediate bleeding, and perforation were comparable. Hot EMR was significantly associated with lower piecemeal resection (59.2% vs. 99.3%, P<0.001), higher en-bloc resection (41.4% vs. 1.4%, P<0.001), and delayed bleeding rate (4% vs. 0.7%, P=0.05) compared to cold EMR.

CONCLUSIONS

Cold EMR has similar efficacy compared to hot EMR for resection of SSP ≥ 10 mm, despite limitations in piecemeal R0 resection rate reporting. Although hot EMR was associated with a higher rate of en-bloc resection, it also showed an increased risk of delayed bleeding compared to cold EMR.

Endoscopic sleeve gastroplasty reintervention score using supervised machine learning

BACKGROUND AND AIMS

Reintervention after endoscopic sleeve gastroplasty (ESG) can be indicated because of postprocedural adverse events from various preinterventional or postprocedural comorbidities. We developed and internally validated an ESG reintervention score (ESG-RS) that determines the individualized risk of reintervention within the first 30 days after ESG.

METHODS

We used data from a sample of 3583 patients who underwent ESG in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database (2016-2021). The least absolute shrinkage and selection operator (LASSO)-penalized regression was used to select the most promising predictors of reintervention after ESG within 30 days. The predictive variables extracted by LASSO regression were entered into multivariate analysis to generate an ESG-RS by using the coefficients of the statistically significant variables. The model performance was assessed using receiver-operator curves by 10-fold cross-validation.

RESULTS

Eleven variables were selected by LASSO regression and used in the final multivariate analysis. The ESG-RS was inferred using 5 factors (history of previous foregut surgery, preoperative anticoagulation use, female gender, American Society of Anesthesiologists class ≥II, and hypertension) weighted by their regression coefficients in the multivariable logistic regression model. The area under the curve of the ESG-RS was .74 (95% confidence interval, .70-.78). For the ESG-RS, the optimal cutpoint was 67.9 (high risk vs low risk), with a sensitivity of .76 and specificity of .71.

CONCLUSIONS

The ESG-RS aids clinicians in preoperative risk stratification of patients undergoing ESG while clarifying factors contributing to a higher risk of reintervention.

Risk of Complications After Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Propensity-Matched Analysis

BACKGROUND

Studies have suggested higher complication rates after endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy.

AIMS

We performed a propensity-matched cohort analysis to assess the risk of ERCP-related complications among pregnant women in the United States.

METHODS

The TriNetX database was analyzed to identify pregnant and non-pregnant females between 18 and 50 years of age who underwent ERCP. One-to-one propensity score matching was performed for age and race. Outcomes included risk of post-ERCP pancreatitis (PEP), gastrointestinal (GI) bleeding, perforation within 7 days, and infections within 30 days of ERCP. Subgroup analysis was performed to assess the risk of PEP based on indication for ERCP.

RESULTS

The risk of PEP was higher in the pregnant cohort compared to controls, 10.3% vs 6.08%, adjusted odds ratio (aOR) 1.77, 95% confidence interval (CI) 1.20-2.61; p = 0.003. We found no difference in the risk of GI bleeding, perforation, and infections between the two cohorts. There was no difference in the risk of PEP in the pregnant cohort compared to controls who underwent ERCP for acute choledocholithiasis (4.2% vs 2.1%, aOR 1.98, 95% CI 0.97-4.03, p = 0.5) or ascending cholangitis (18.6% vs 14.7%, aOR 1.32, 95% CI 0.52-3.39, p = 0.55). There was no difference in the risk of PEP in the pregnant cohort after sensitivity analysis based on age, race, obesity, and indomethacin use.

CONCLUSION

Pregnant females are at an increased risk of PEP but not GI bleeding, perforation, and infections when compared to non-pregnant controls. Clinicians should be cautious when proceeding with ERCP during pregnancy.

Safety and Efficacy of Powered Non-Thermal Endoscopic Resection Device for Removal of Colonic Polyps: A Systematic Review and Meta-Analysis

Background

Endoscopic mucosal resection is a frequently employed method for removing colonic polyps. Nonetheless, the recurrence of these polyps over a healed submucosal base can complicate the extraction of leftover lesions through standard procedures. EndoRotor®, a non-thermal device specifically designed for endoscopic mucosal resection, has recently been assessed for its utility in removing colonic polyps, non-dysplastic Barrett's esophagus, and pancreatic necrosis. We conducted a systematic review and meta-analysis to ascertain the safety and efficacy of EndoRotor® in resecting scared or recurrence colonic polyps.

Methods

We conducted an exhaustive review of existing literature using databases such as Medline, Embase, Web of Science, and the Cochrane Library until January 2023. Our aim was to find all studies that assessed the safety of non-thermal endoscopic resection devices in removing colonic polyps. The primary outcome we focused on was the rate of technical success. Secondary outcomes that we considered included the frequency of remaining lesions and instances of adverse events. To analyze these data, we used comprehensive meta-analysis software.

Results

Our analysis incorporated three studies comprising 54 patients who underwent resection of 60 lesions. The combined technical success rate was 93.9% (95% confidence interval (CI): 77.7-98.6%, I2 = 25.5%). In patients who had another endoscopic examination, 20 were found to have a residual lesion. After the initial session, the combined rate of remaining lesions was 39.8% (95% CI: 15.3-70.8%, I2 = 74.5%). There were eight occurrences of intraoperative bleeding and four instances of bleeding post-procedure. The combined rate of intraoperative bleeding was 13.2% (95% CI: 6.7-24.3%, I2 = 0%), and post-procedure bleeding stood at 8.5% (95% CI: 3.4-19.8%, I2 = 0%). Only one major bleeding event was recorded, and no cases of perforation were reported.

Conclusion

Our research indicates that the EndoRotor® effectively removes scarred colonic polyps, though the rate of remaining lesions is significant, potentially necessitating several sessions for a thorough removal. There is a need for broader prospective studies, mainly randomized controlled trials, to further assess EndoRotor®'s efficiency and safety in eliminating colonic polyps.

Delaying Cardiac Catheterization in Favor of Endoscopy in Non-ST Elevation Myocardial Infarction Patients Is Associated with Worse Outcomes: A Nationwide Analysis

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) in non-ST-elevation myocardial infarction (NSTEMI) is associated with substantial morbidity and mortality. We evaluated inpatient outcomes of esophagogastroduodenoscopy (EGD) before cardiac catheterization in patients with NSTEMI and NVUGIB.

METHODS

We utilized the National Readmission Database (2016-2019) to identify all index hospitalizations with a primary diagnosis of NSTEMI and a secondary diagnosis of NVUGIB that underwent EGD before cardiac catheterization (cases). A matched comparison cohort of similar hospitalizations that undergo EGD after cardiac catheterization were identified (controls) after 1:1 propensity score matching for age, gender, cardiac comorbidities, causes, and severity of bleeding.

RESULTS

A total of 796 cases were matched with 796 controls. There was a higher median length of hospital stay (8 vs. 5 days, P = 0.01) and median hospital charges ($111,218 vs. $99,115, P = 0.002) for cases compared to controls. There was a higher all-cause inpatient mortality in cases compared to controls (5.5% vs. 3.9%, P = 0.26). Furthermore, there was a higher proportion of patients with ICU admission (7% vs. 3%, P < 0.001), septic shock (7.1% vs. 5.8%, P = 0.41), atrial fibrillation (27.1% vs. 19.8%, P < 0.001) and acute kidney injury (42.8% vs. 29.1%, P < 0.001) for cases compared to controls.

CONCLUSION

Delaying cardiac catheterization in favor of EGD is associated with increased hospital stay, costs, and cardiac complications. Further studies are warranted to establish our findings.

Patient adverse events and technical failures with the bravo capsule pH system: insights from the MAUDE database

BACKGROUND

The BRAVO pH monitor system can benefit patients with ongoing GERD symptoms despite treatment and/or atypical symptoms. We aim to investigate the number and type of complications associated with the BRAVO pH capsule.

METHODS

From April 2016 through February 2021, we analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database.

RESULTS

During the study period, approximately 1,651 reports were identified with 2391 cases associated with a device failure, and 254 reporting a patient-related adverse event. Most device complications were due to aspiration n = 153), followed by reported pain (n = 79), injury (unspecified) (n = 63), and additional radiologic imaging (n = 44). Laceration and bleeding accounted for 29 and 19 cases. Furthermore, three patients suffered perforation. Most device failures were due to loss or failure of the Bravo capsule to bond or adhere to the esophageal mucosa as planned (n = 1269), followed by an activation or positioning failure (n = 972), premature detachment of device (n = 284), and failure of the device to record or transmit data (n = 158).

CONCLUSIONS

Findings from the MAUDE database highlight the risk of aspiration, hemorrhage/bleeding, perforation, injury, and retention as potential complications of BRAVO capsule placement.

Device malfunctions with use of EUS-guided fine-needle biopsy devices: Analysis of the MAUDE database

Background

The safety of endoscopic ultrasound-guided tissue acquisition through fine-needle biopsy devices is well-established in clinical trials. The real-world experience of using these devices is not known. The authors analyzed the postmarketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to answer this question.

Methods

The Food and Drug Administration MAUDE database from January 2012 to June 2022 was accessed to evaluate for device malfunctions and patient-related adverse consequences of these malfunctions.

Results

There were 344 device-related issues. Most issues were due to detachment or breakage of the device (n = 185 [53.7%]). Seventy-six of the breakages (40.8%) occurred during the procedure, whereas 89 cases (47.8%) occurred while removing the needle from the endoscope. The most common site of tissue biopsy at the time of needle breakage was the pancreas (44 [23.8%]).The common patient-related adverse events were retained foreign body (n = 50 [14.5%]) followed by bleeding (16, 4.6%). Six patients (3.4%) required a second intervention for removal of the retained foreign bodies including surgery in 2 cases. The device breakage damaged the endoscope in 3 cases (1.7%), and there was 1 case of needlestick injury to the nurse.

Conclusion

The fine-needle biopsy devices can be associated with needle breakage and bending; these adverse events were not previously reported. Needle breakages can result in a retained foreign body that may require additional procedures including surgery. These real-world findings from the MAUDE database may inform clinical decisions and help improve clinical outcomes.

Comparable Efficacy of Laser-Cut and Braided Self Expanding Metallic Biliary Stent: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

In patients with unresectable malignant biliary obstruction (MBO), endoscopic biliary drainage is the treatment of choice. Self-expanding metallic stents (SEMS) are mainly used for this purpose, and data is limited on the comparative outcomes of laser-cut versus braided SEMS. Herein, we performed the first systematic review and meta-analysis to study the effectiveness and safety of braided and laser-cut SEMS in MBO.

METHODS

Multiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of braided and laser-cut SEMS in MBO. Outcomes of interest were technical and clinical success, recurrent biliary obstruction, and adverse events. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity.

RESULTS

Seven studies were included in the final analysis. (Laser-cut: 271 patients, 46% females, mean age 70 years; and braided: 282 patients, 47% females, mean age 72 years). The pooled rate of technical success and clinical success with laser-cut SEMS was 99% (95% CI [95-99; I2 = 0%]), 86% [60-96; I2 = 74%], and 98% [96-99; I2 = 0%], 89% [74-95; I2 = 78%] with braided. The pooled rate of recurrent biliary obstruction with laser-cut SEMS was 26% [14-43; I2 = 88%] and 12% [5-27; I2 = 56%) with braided. Pooled total adverse events were 11% [5-21; I2 = 77%] in laser-cut and 12% [6-24; I2 = 63%] in braided.

CONCLUSION

Our meta-analysis demonstrates similar clinical outcomes with laser-cut and braided SEMS in MBO. Given the comparable performance, a cost-effectiveness analysis might help in choosing one type versus another in patients with MBO.

New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

BACKGROUND

Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB.

METHODS

We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI).

RESULTS

The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I2 = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I2 = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP.

CONCLUSION

SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.

A Systematic Review and Meta-Analysis: A Prior Appendectomy Does Not Increase the Risk of Severe Clostridioides difficile Infection or Recurrence

BACKGROUND AND OBJECTIVES

There is conflicting evidence regarding the association between a prior appendectomy and severity of Clostridioides difficile infection. The aim of this study was to perform a systematic review and meta-analysis to evaluate this association.

PATIENTS AND METHODS

Comprehensive review of multiple databases was performed up to May 2022. The primary outcome assessed was the rate of severe Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix. The secondary outcomes assessed were recurrence, mortality, and colectomy rates associated with Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix.

RESULTS

Eight studies with 666 patients with a prior appendectomy and 3580 patients without an appendectomy were included. The odds ratio of severe Clostridioides difficile infection in patients who underwent prior appendectomy was 1.03 (95% CI 0.6-1.78, p = 0.92). The odds ratio of recurrence in patients who underwent prior appendectomy was 1.29 (95% CI 0.82-2.02, p = 0.28). The odds ratio of colectomy due to Clostridioides difficile infection in patients who underwent prior appendectomy was 2.16 (95% CI 1.27-3.67, p = 0.004). The odds ratio of mortality due to Clostridioides difficile infection in patients with a prior appendectomy was 0.92 (95% CI 0.62-1.37, p = 0.68).

CONCLUSION

Patients with appendectomy are not at increased risk for developing severe Clostridioides difficile infection or recurrence. Further prospective studies are needed to establish these associations.

Role of Duodenal Bulb Biopsy in Diagnosing Suspected Celiac Disease in Adult Patients: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Current guidelines recommend multiple biopsies from the first (D1) and second (D2) part of duodenum to establish a diagnosis of celiac disease. In this meta-analysis we aimed to find whether D1 biopsy can increase the diagnostic yield of adult celiac disease.

METHODS

Literature databases were searched until January 2023 for studies reporting diagnosis of celiac disease in the adult population using D1 biopsy. Meta-analysis was done using a random-effects model. Heterogeneity was assessed by I2% and 95% prediction interval statistics. Measured outcomes were diagnostic yield with D1 and D2 biopsies and from 4 versus 2 biopsy samples.

RESULTS

A total of 16 studies were included in the final analysis. The pooled diagnostic rate of celiac disease from D1 biopsy was 77.4% [95% CI (64.7-86.5, I2 94%)] and from D2 biopsy was 75.3% [60.8-85.7, I2 96%]. The pooled rate of increase in diagnostic yield with D1 biopsy was 6.9% I [4.6-10.2, I2 66%]. The pooled diagnosis rate with 2 biopsy samples were 77.3% [50-92, I2 93%] and 86.4% I [58.4-96.7, I2 87%] from D1 and D2 respectively, whereas that with 4 biopsy samples were 83.3% [49.8-96.2, I2 76%] and 70.5% I [51-84.6, I2 96%] from D1 and D2, respectively, the difference being non-significant.

CONCLUSION

Our study demonstrates that taking 4 biopsy samples does not incur any additional diagnostic value over taking 2 biopsy samples from each duodenum segment. Although biopsy from the D1 and D2 has similar diagnostic yield in the adult population, there was an overall increase in diagnostic yield with D1 biopsy, especially in those with a patchy disease distribution.

Vonoprazan versus lansoprazole in erosive esophagitis - A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Proton-pump inhibitors (PPIs) are the mainstay of treatment in erosive esophagitis (EE). An alternative to PPIs in EE is Vonoprazan, a potassium competitive acid blocker. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing vonoprazan to lansoprazole.

METHODS

Multiple databases searched through November 2022. Meta-analysis was performed to assess endoscopic healing at two, four and eight weeks, including for patients with severe EE (Los Angeles C/D). Serious adverse events (SAE) leading to drug discontinuation were assessed. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Four RCTs with 2208 patients were included in the final analysis. Vonoprazan 20 mg once-daily was compared to lansoprazole 30 mg once-daily dosing. Among all patients, at two and eight weeks post-treatment, vonoprazan resulted in significantly higher rates of endoscopic healing as compared to lansoprazole, risk ratios (RR) 1.1, p<0.001 and RR 1.04, p=0.03. The same effect was not observed at four weeks, RR 1.03 (CI 0.99-1.06, I2=0%) following therapy. Among patients with severe EE, vonoprazan resulted in higher rates of endoscopic healing at two weeks, RR 1.3 (1.2-1.4, I2=47%), p=<0.001, at four weeks, RR 1.2 (1.1-1.3, I2=36%), p=<0.001 and at eight weeks post-treatment, RR 1.1 (CI 1.03-1.3, I2=79%), p=0.009. We found no significant difference in the overall pooled rate of SAE and pooled rate of adverse events leading to drug discontinuation. Finally, the overall certainty of evidence for our main summary estimates was rated as high (grade A).

CONCLUSION

Based on limited number of published non-inferiority RCTs, our analysis demonstrates that among patients with EE, vonoprazan 20 mg once-daily dosing achieves comparable and in those with severe EE, higher endoscopic healing rates as compared to lansoprazole 30 mg once-daily dosing. Both drugs have a comparable safety profile.

EUS-guided therapies for primary and secondary prophylaxis in gastric varices-An updated systematic review and meta-analysis

Background and Objectives

Gastric varices (GVs) are associated with a higher risk of uncontrolled bleeding and death when compared with esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding primary prophylaxis continue to emerge. Recently, EUS-guided therapies have been used in GV bleeding.

Methods

We conducted a comprehensive search of several major databases from inception to June 2022. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and rebleeding with EUS-guided therapy in primary and secondary prophylaxis. Overall adverse events and technical failures were assessed. Random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I2 % statistics.

Results

Eighteen studies with 604 patients were included. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (confidence interval [CI], 81.1-95.2; I2 = 0). With combination EUS-glue and coil therapy, the rate was 95.4% (CI, 86.7%-98.5%; I2 = 0). Pooled rate of posttherapy GV bleeding was 4.9% (CI, 1.8%-12.4%; I2 = 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI, 86.8%-95.2%; I2 = 12). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 94.3% (CI, 88.9%-97.1%; I2 = 0), 95.5% (CI, 80.3%-99.1%; I2 = 0), and 88.7% (CI, 76%-95.1%; I2 = 14), respectively. Pooled rate of GV obliteration was 83.6% (CI, 71.5%-91.2%; I2 = 74). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 84.6% (CI, 75.9%-90.6%; I2 = 31), 92.3% (CI, 81.1%-97.1%; I2 = 0), and 84.5% (CI, 50.8%-96.7%; I2 = 75), respectively. Pooled rates of GV rebleeding and recurrence were 18.1% (CI, 13.1%-24.3%; I2 = 16) and 20.6% (CI, 9.3%-39.5%; I2 = 66), respectively.

Conclusion

Our analysis shows that EUS-guided therapy for GVs is technically feasible and clinically successful in both primary and secondary prophylaxis of GV.

Comparable Short-Term Weight Loss and Safety of Endoscopic Sleeve Gastroplasty in Diabetic and Non-diabetic Patients

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a highly effective endo bariatric procedure. Data on outcomes of ESG in patients with diabetes mellitus (DM) compared to non-diabetics are limited.

AIMS

We aim to assess differences in clinical outcomes of ESG in DM patients in North America.

METHODS

We used the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database from 2016 to 2021 to identify all DM patients who underwent ESG as the primary procedure for weight loss. A 1:1 propensity score matched cohort of non-DM patients served as controls. Patient characteristics, clinical outcomes, and complications were compared and analyzed. Adult patients with Class I obesity and above were included.

RESULTS

After matching, 310 DM and non-DM patients that underwent ESG were compared. The median % BMI decrease (3.3% vs. 3.1%, P = 0.62) and median total body weight loss (%TBWL) (4.3% vs. 4%, P = 0.75) in 30 days were similar in the DM compared to non-DM cohorts. A similar proportion of patients with major adverse events (AEs) were present after ESG in the DM (1.6% vs. 1.3%, P = 0.74) compared to the non-DM cohort. The DM cohort had more patients with 30-day readmissions (3.2% vs. 1.9%, P = 0.08) than the non-DM cohort. %TBWL was similar in patients with HbA1c < 9% compared to ≥ 9%, (4.3% each, P = 0.33) with comparable AEs.

CONCLUSION

ESG is a safe procedure in DM patients, without an increase in AEs, and it shows similar short-term weight loss compared to non-DM patients.

Gastrointestinal treatment-related adverse events of combined immune checkpoint inhibitors: a meta-analysis

Introduction: Combined immune checkpoint inhibitors can cause gastrointestinal adverse events. Methods: We performed a meta-analysis of pooled colonic, hepatic and pancreatic treatment-related adverse events of combined ICI. Results: 53 trials reporting treatment-related adverse events in 6581 patients. All grade diarrhea was the most common adverse event seen in 25.4% patients, followed by all grade hepatitis in nearly 13% patients and pancreatitis in nearly 7.5% patients. Conclusion: Our study provides pooled data of treatment-related adverse events from different combination immune checkpoint inhibitors use in solid tumors and demonstrates a high incidence of all grades and ≥3 grade gastrointestinal adverse events. Further studies are required to characterize these adverse events and assess their overall impact on treatment course and outcomes.

G-POEM for gastroparesis: past, present and future

PURPOSE OF REVIEW

Gastroparesis is a chronic debilitating condition with rising incidence and healthcare burden. As abdominal surgeries, diabetes, viral infections and autoimmune diseases become more prevalent, gastroparesis will continue to upsurge. Conservative treatment options for gastroparesis are limited by their side effects and short-term efficacy. Gastric endoscopic pyloromyotomy (G-POEM) is a novel incisionless endosurgical technique with excellent long-term outcomes. This review is in time, as the demand for G-POEM will continue to escalate.

RECENT FINDINGS

This review encompasses the conservative and nonconservative treatment options for gastroparesis. G-POEM is a nonconservative treatment option, and the aim of this review is to discuss the variations in technique of G-POEM, short-term and long-term clinical efficacy of G-POEM and adverse events associated with it.

SUMMARY

G-POEM has high technical and clinical success with minimal adverse events. G-POEM outcomes are similar or superior when compared with other treatment options for refractory gastroparesis. G-POEM is being widely adopted and will become the preferred treatment choice in patients with refractory gastroparesis.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes.

Methods

Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software.

Results

The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I² = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG.

Conclusion

PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

Single-incision needle-knife biopsy for the diagnosis of GI subepithelial tumors: a systematic review and meta-analysis

BACKGROUND AND AIMS

A histologic diagnosis of GI subepithelial tumors (SETs) is important because of the malignant potential of these lesions. The current modalities of choice, including EUS-guided FNA and biopsy (EUS-FNA/FNB) have demonstrated suboptimal diagnostic success. Single-incision with needle-knife (SINK) biopsy has emerged as an alternative diagnostic approach to increase tissue acquisition and diagnostic success. The aim of this study was to perform a systematic review and meta-analysis to evaluate the technical success, diagnostic success, and adverse events of SINK biopsy.

METHODS

We searched multiple databases including PubMed, EMBASE, CINAHL, Cochrane, Web of Science, and Google Scholar from inception to July 2022. The primary outcomes assessed were the technical success and diagnostic success of SINK in GI SETs. The secondary outcomes assessed were adverse events and whether immunohistochemical analysis could be successfully performed on tissue samples obtained via SINK.

RESULTS

Seven studies with a total of 219 SINK biopsy procedures were included in this meta-analysis. The technical success rate was 98.1% (95% CI, 94.9%-99.3%; P = .000; I² = .0%), and the diagnostic success rate was 87.9% (95% CI, 82.6%-91.7%; P = .000; I² = .0%). The immunohistochemical success rate was 88.3% (95% CI, 78.7%-93.9%; P = .000; I² = 3.5%). The rate of adverse events was 7.5% (95% CI, 4.3%-12.7%; P = .00; I² = 7.2%), and bleeding was the most common adverse event.

CONCLUSION

SINK biopsy is a safe diagnostic procedure with a high technical and diagnostic success in patients with GI SET. Further randomized controlled trials and direct comparison studies are needed to validate these findings.

Predictors of Fecal Microbiota Transplant Failure in Clostridioides difficile Infection : An Updated Meta-analysis

INTRODUCTION AND AIM

Fecal microbiota transplantation (FMT) is an effective treatment for recurrent/refractory Clostridioides difficile infection (CDI) with a 10% to 20% risk of recurrence after a single FMT. In this meta-analysis, we aimed to evaluate the predictors of FMT failure.

METHODS

A comprehensive search of MEDLINE, Embase, Cochrane, and Web of Science databases through July 2021 was performed. All studies that evaluated risk factors associated with FMT failure in a multivariate model were included. We calculated pooled odds ratios with 95% confidence intervals for risk factors reported in ≥3 studies using a random-effects model.

RESULTS

Twenty studies involving 4327 patients (63.6% females) with recurrent/refractory CDI who underwent FMT were included. FMT failed in 705 patients (16.3%) with 2 to 3 months of follow-up in most studies. A total of 12 different risk factors were reported in a multivariate model in ≥3 studies. Meta-analysis showed that advanced age, severe CDI, inflammatory bowel disease, peri-FMT use of non-CDI antibiotics, prior CDI-related hospitalizations, inpatient status, and poor quality of bowel preparation were significant predictors of FMT failure. Charlson Comorbidity Index, female gender, immunosuppressed status, patient-directed donor, and number of CDI recurrences were not associated with FMT failure.

CONCLUSIONS

Adequate bowel preparation at the time of FMT and optimizing antibiotic stewardship practices in the peri-FMT period can improve the success of FMT. Patients with nonmodifiable risk factors should be counseled about the risk of FMT failure. Our results may help develop a risk stratification model to predict FMT failure in CDI patients.

Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction - A systematic review and meta-analysis

Background and Objectives

ERCP is the first line of treatment for benign and malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. Recently, several studies have evaluated the role of EUS-BD in the management of benign biliary obstruction. This meta-analysis evaluates the efficacy and safety of EUS-BD in the management of benign biliary obstruction.

Methods

We reviewed several databases from inception to July 8, 2022, to identify studies evaluating the efficacy and safety of EUS-BD in the management of benign biliary obstruction. Our outcomes of interest were technical success, clinical success, and adverse events. Pooled rates with 95% confidence intervals (CIs) for all outcomes were calculated using a random effects model. Subgroup analyses were performed including patients with normal anatomy versus surgically altered anatomy (SAA). Heterogeneity was assessed by I2 statistic.

Results

We included 14 studies with 329 patients. The pooled rate (95% CI) of technical success was 88% (83%, 92%). The pooled rate (95% CI) of technical success for patients with SAA and normal anatomy was 92% (85%, 96%) and 83% (75%, 89%), respectively. The pooled rates (95% CI) of clinical success and adverse events were 89% (83%, 93%) and 19% (13%, 26%), respectively. We found low heterogeneity in most of the analyses.

Conclusions

EUS-BD is an effective and safe option in patients with benign biliary obstruction and should be considered after a failed attempt at ERCP or when ERCP is not technically possible.

EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes

EUS-guided liver biopsy (EUS-LB) has gained momentum in recent years, especially with availability of newer needle designs. Given the emerging comparative data on EUS-LB with second-generation needles and percutaneous LB (PC-LB), we conducted a systematic review and meta-analysis to compare the safety and efficacy of the two techniques. We searched multiple databases from inception through November 2021 to identify studies comparing outcomes of EUS-LB and PC-LB. Pooled estimates were calculated using a random-effects model, and the results were expressed in terms of pooled proportions and odds ratio (OR) along with relevant 95% confidence intervals (CIs). Five studies with 748 patients were included in the final analysis. EUS-LB was performed in 276 patients and PC-LB in 472 patients. Across all studies, PC-LB had an overall higher diagnostic accuracy than EUS-LB, 98.6% confidence interval (CI: 94.7-99.7) versus 88.3% (49.6-98.3), OR: 1.65, P = 0.04. On assessing data from randomized controlled trials, there was no difference between the two. While pooled diagnostic adequacy and overall adverse events were not significantly different between PC-LB and EUS-LB, the former was superior in terms of the mean number of complete portal tracts (CPT) and total specimen length. PC-LB and EUS-LB produce similar results. PC-LB allows obtaining longer samples and more CPT. Further studies are needed to see if these trends hold up as more providers begin to perform EUS-LB.

Early (<4 weeks) versus standard (≥4 weeks) endoscopic drainage of pancreatic walled-off fluid collections: a systematic review and meta-analysis

BACKGROUND AND AIMS

Previous studies have demonstrated that the ideal time for drainage of walled-off pancreatic fluid collections is 4 to 6 weeks after their development. However, some pancreatic collections, notably infected pancreatic fluid collections, require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate the clinical efficacy and safety of EUS-guided drainage of pancreatic fluid collections <4 weeks after development compared with ≥4 weeks after development.

METHODS

Search strategies were developed for PubMed, Embase, and Cochrane Library databases from inception. Outcomes of interest were technical success, defined as successful endoscopic placement of a lumen-apposing metal stent; clinical success, defined as a reduction in cystic collection size; and procedure-related adverse events. A random-effects model was used for analysis, and results are expressed as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Six studies (630 patients) were included in our final analysis, in which 182 patients (28.9%) were enrolled in the early drainage cohort and 448 patients (71.1%) in the standard drainage cohort. The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort versus 128 ± 19.7 mm for the standard cohort. Overall, technical success was equal in both cohorts. Clinical success did not favor either standard drainage or early drainage (OR, .39; 95% CI, .13-1.22; P = .11). No statistically significant differences were found in overall adverse events (OR, 1.67; 95% CI, .63-4.45; P = .31) or mortality (OR, 1.14; 95% CI, .29-4.48; P = .85). Hospital stay was longer for patients undergoing early drainage compared with standard drainage (23.7 vs 16.0 days, respectively).

CONCLUSIONS

Both early (<4 weeks) and standard (≥4 weeks) drainage of walled-off pancreatic fluid collections offer similar technical and clinical outcomes. Patients requiring endoscopic drainage should not be delayed for 4 weeks.

Endoscopic management of pancreatic walled-off necrosis

Pancreatic walled-off necrosis (WON) is a complication of severe pancreatitis. Endoscopic transmural drainage has been recognized as the first-line treatment for pancreatic fluid collections. Endoscopy offers a minimally invasive approach when compared to surgical drainage. Today, endoscopists may choose to use self-expanding metal stents, pigtail stents, or lumen-apposing metal stents to facilitate drainage of fluid collections. Current data suggest that all 3 approaches yield similar outcomes. It was previously thought that drainage should be performed 4 weeks from the initial event of pancreatitis, theoretically allowing the capsule to mature. However, current data show that both early (<4 weeks) and standard (≥4 weeks) endoscopic drainage are comparable. Herein, we provide an up-to-date state-of-the-art review of the indications, techniques, innovations, outcomes, and future perspectives following drainage of pancreatic WON.

Multianalyte Serum Biomarker Panel for Early Detection of Pancreatic Adenocarcinoma

PURPOSE

We determined whether a large, multianalyte panel of circulating biomarkers can improve detection of early-stage pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

We defined a biologically relevant subspace of blood analytes on the basis of previous identification in premalignant lesions or early-stage PDAC and evaluated each in pilot studies. The 31 analytes that met minimum diagnostic accuracy were measured in serum of 837 subjects (461 healthy, 194 benign pancreatic disease, and 182 early-stage PDAC). We used machine learning to develop classification algorithms using the relationship between subjects on the basis of their changes across the predictors. Model performance was subsequently evaluated in an independent validation data set from 186 additional subjects.

RESULTS

A classification model was trained on 669 subjects (358 healthy, 159 benign, and 152 early-stage PDAC). Model evaluation on a hold-out test set of 168 subjects (103 healthy, 35 benign, and 30 early-stage PDAC) yielded an area under the receiver operating characteristic curve (AUC) of 0.920 for classification of PDAC from non-PDAC (benign and healthy controls) and an AUC of 0.944 for PDAC versus healthy controls. The algorithm was then validated in 146 subsequent cases presenting with pancreatic disease (73 benign pancreatic disease and 73 early- and late-stage PDAC cases) and 40 healthy control subjects. The validation set yielded an AUC of 0.919 for classification of PDAC from non-PDAC and an AUC of 0.925 for PDAC versus healthy controls.

CONCLUSION

Individually weak serum biomarkers can be combined into a strong classification algorithm to develop a blood test to identify patients who may benefit from further testing.

Efficacy of topical hemostatic agents in malignancy-related GI bleeding: a systematic review and meta-analysis

BACKGROUND AND AIMS

Despite advances in endoscopic therapies, malignancy-related GI bleeding remains difficult to manage with high rates of treatment failure and rebleeding. Topical hemostatic agents (THAs) are easier to apply to the wide bleeding surface of tumors. We conducted this systematic review and meta-analysis to evaluate the efficacy of THAs in malignancy-related GI bleeding.

METHODS

We conducted a comprehensive search of multiple electronic databases to identify studies reporting on the use of THAs in malignancy-related GI bleeding. The primary outcome was the achievement of hemostasis; secondary outcomes were early rebleeding (≤3 days), delayed rebleeding (>3 days), aggregate rebleeding, all-cause mortality, and GI bleeding-related mortality. A meta-analysis of proportions was done for all outcomes.

RESULTS

Out of 355 citations, 16 studies with 530 patients were included. Primary hemostasis was achieved in 94.1% (95% confidence interval [CI], 91.5-96.0). Early rebleeding was seen in 13.9% (95% CI, 9.7-19.4) and delayed rebleeding in 11.4% (95% CI, 5.8-21.1). Aggregate rebleeding was seen in 24.2% (95% CI, 18.5-31.0). All-cause mortality was 33.1% (95% CI, 23.7-44.0), whereas GI bleeding-related mortality occurred in 5.9% (95% CI, 2.2%-14.8).

CONCLUSIONS

THAs are highly effective for achieving primary hemostasis in malignancy-related GI bleeding. It should be considered as an alternative to traditional endotherapy methods in malignancy-related GI bleeding. Future studies should be designed to evaluate its efficacy and safety as a primary method of hemostasis as compared with traditional endotherapy measures.

Patient-related adverse events and device failures associated with commercially available enteral or duodenal self-expanding metal stents: an analysis of the MAUDE database

BACKGROUND AND AIMS

Duodenal stents are widely used to treat patients with malignant gastric outlet obstruction (MGOO), most commonly from pancreatic cancer. The WallFlex (Boston Scientific, Natick, Mass, USA) and Evolution (Cook Endoscopy, Winston-Salem, NC, USA) duodenal stents are in widespread use for treating MGOO. The objective of this study was to analyze device failures and patient-related adverse events reported to the U.S. Food and Drug Administration (FDA) for these 2 stents.

METHODS

We analyzed postmarketing surveillance data on the WallFlex and Evolution duodenal stents from January 2000 to January 2022 through the FDA's Manufacturer and User Facility Device Experience (MAUDE) database (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm).

RESULTS

One hundred fifty-four MAUDE reports were identified and analyzed, from which 176 device failures and 186 patient-related adverse events were identified. Device-related failures for the WallFlex stent were delivery system failure (15.4%) and failure to activate the stent (13.2%). Device failures for the Evolution stent were failure to activate the stent (16.5%) and delivery system failure (15.3%). Patient-related adverse events for the WallFlex stent were perforation (18.9%), death (6.6%), and hemorrhage (3.8%), whereas patient-related adverse events for the Evolution duodenal stent were obstruction (16.3%), perforation (6.3%), aspiration (3.8%), and fragments of broken delivery system left in the patient (3.8%).

CONCLUSIONS

Both stents are associated with device failures such as failure to activate the stent, stent migration, and occlusion by tumor growth. Despite high success rates, duodenal stents can be associated with serious device failures and patient-related adverse events.

Risk of post sphincterotomy bleeding with antiplatelet and anticoagulant use - A propensity-matched analysis of United States Collaborative Network

BACKGROUND

Gastrointestinal (GI) bleeding following endoscopic retrograde cholangiopancreatography (ERCP) is a serious adverse event and most commonly occurs after endoscopic biliary and/or pancreatic sphincterotomy. While the strength of available evidence for post sphincterotomy GI bleeding risk is high for therapeutic warfarin and heparin, it remains unknown for clopidogrel and prasugrel. We conducted a retrospective United States (US)-based propensity-matched cohort study, to assess the risk of post sphincterotomy bleeding in patients on anticoagulant (AC) and antiplatelet (APT) therapy.

METHODS

We analyzed the US Collaborative Network in the TriNetX platform through December 27^th, 2022, to include patients on APT and AC therapy who underwent ERCP within 7 days of hospitalization. One-to-one propensity-matching was performed. The primary outcome was the incidence of GI bleeding within 7 days of sphincterotomy. Secondary outcomes included need for blood transfusion, intensive care unit (ICU) care, and all-cause mortality within 30 days of bleeding.

RESULTS

Overall, 2,806 patients (1,806 in the AC and 1000 in APT cohorts) underwent ERCP with sphincterotomy. One-to-one (1:1) propensity score matching was performed for age, BMI >= 30, gender, race, ethnicity, diabetes mellitus, nicotine dependence, presence and severity of chronic kidney disease, cirrhosis, and thrombocytopenia between the cohorts. Patients in both AC and APT cohorts had an increased risk of post sphincterotomy bleeding compared to matched controls, adjusted odds ratio (aOR) 3.6 (95% Confidence Interval (CI) 2.58 - 5.06) and aOR 2.2 (95% CI 1.43 - 3.56), respectively. While heparin bridging therapy and concurrent use of aspirin did not further increase the risk of GI bleeding, resumption of AC within 24 hours post procedure did. Patients in neither cohort were at an increased risk for blood transfusion, ICU care or mortality.

CONCLUSION

Our database analysis shows that patients on AC and APT are indeed at a higher risk of post sphincterotomy bleeding, compared to matched controls. Appropriate drug cessation period or alternative biliary decompression modalities may be utilized in these patients.

Efficacy and safety of EUS-guided gallbladder drainage for rescue treatment of malignant biliary obstruction: A systematic review and meta-analysis

ERCP is the first line of treatment for malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. EUS-guided gallbladder drainage (EUS-GBD) has been suggested as a rescue treatment for patients who fail EUS-BD and ERCP. In this meta-analysis, we have evaluated the efficacy and safety of EUS-GBD as a rescue treatment of malignant biliary obstruction after failed ERCP and EUS-BD. We reviewed several databases from inception to August 27, 2021, to identify studies that evaluated the efficacy and/or safety of EUS-GBD as a rescue treatment in the management of malignant biliary obstruction after failed ERCP and EUS-BD. Our outcomes of interest were clinical success, adverse events, technical success, stent dysfunction requiring intervention, and difference in mean pre- and postprocedure bilirubin. We calculated pooled rates with 95% confidence intervals (CI) for categorical variables and standardized mean difference (SMD) with 95% CI for continuous variables. We analyzed data using a random-effects model. We included five studies with 104 patients. Pooled rates (95% CI) of clinical success and adverse events were 85% (76%, 91%) and 13% (7%, 21%). Pooled rate (95% CI) for stent dysfunction requiring intervention was 9% (4%, 21%). The postprocedure mean bilirubin was significantly lower compared to preprocedure bilirubin, SMD (95% CI): -1.12 (-1.62--0.61). EUS-GBD is a safe and effective option to achieve biliary drainage after unsuccessful ERCP and EUS-BD in patients with malignant biliary obstruction.

Diagnostic accuracy of EUS-guided fine-needle biopsy sampling by macroscopic on-site evaluation: a systematic review and meta-analysis

BACKGROUND AND AIMS

Assessment of EUS-guided fine-needle tissue acquisition by macroscopic on-site evaluation (MOSE) is gathering attention. Studies report good diagnostic parameters with MOSE; however, the overall data are limited. We conducted this systematic review and meta-analysis to report on the pooled diagnostic assessment parameters of EUS-guided tissue acquisition by MOSE using fine-needle biopsy sampling (FNB).

METHODS

Multiple databases were searched (from inception to December 2021), and studies that reported on the diagnostic assessment of EUS-guided tissue acquisition by MOSE were selected. Pooled diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were calculated by standard meta-analysis methods following the random-effects model. Heterogeneity was assessed by I² statistics.

RESULTS

Fourteen studies were included in the analysis, and 1508 lesions were biopsy sampled in 1489 patients undergoing EUS-guided tissue acquisition. MOSE definition included a visible core of tissue with opacity and "wormlike" features of adequate size and length (≥4 mm). The pooled accuracy of FNA and/or FNB specimens in yielding a pathologic diagnosis by MOSE was 91.3% (95% confidence interval [CI], 88.6-93.3; I² = 66%), pooled sensitivity was 91.5% (95% CI, 88.6-93.6; I² = 66%), pooled specificity was 98.9% (95% CI, 96.6-99.7; I² = 80%), pooled positive predictive value was 98.8% (95% CI, 97.4-99.5; I² = 33%), and pooled negative predictive value was 55.5% (95% CI, 46.9-63.9; I² = 95%). Subgroup analyses by newer-generation FNB needles demonstrated similar pooled rates, with minimal adverse events (2.5%; 95% CI, 1.5-3.9; I² = 21%).

CONCLUSIONS

Excellent pooled diagnostic accuracy parameters were demonstrated in EUS-guided tissue acquisition by FNB using the MOSE method.