Endoscopic Ultrasound-Guided vs Endoscopic Retrograde Cholangiopancreatography-Guided Biliary Drainage as Primary Approach to Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary drainage in malignant distal biliary obstruction (MDBO). This meta-analysis of randomized controlled trials (RCTs) aims to compare the outcomes of these 2 approaches.

METHODS

Electronic databases from January 2005 through December 2023 were searched for RCTs comparing outcomes of EUS-BD and ERCP for treating MDBO. Pooled proportions, risk ratio (RR), and odds ratio were calculated using random-effects models.

RESULTS

Five RCTs comprising 519 patients were included in the final analysis. The pooled RR for overall technical success with EUS-BD compared with ERCP was 1.05 (95% confidence interval [CI] = 0.96-1.16, P = 0.246, I2 = 61%) and for clinical success was 0.99 (95% CI = 0.95-1.04, P = 0.850, I2 = 0%). The pooled rate of procedure-related pancreatitis was 7.20% (95% CI = 3.60-13.80, I2 = 34%) in the ERCP group compared with zero in the EUS-BD group. The pooled RR for stent dysfunction with EUS-BD compared with ERCP was 0.48 (95% CI = 0.28-0.83, P = 0.008, I2 = 7%). The weighted mean procedure time was 13.43 (SD = 10.12) minutes for EUS-BD compared with 21.06 (SD = 6.64) minutes for ERCP. The mean stent patency was 194.11 (SD = 52.12) days in the EUS-BD group and 187 (SD = 60.70) days in the ERCP group.

DISCUSSION

EUS-BD is an efficient and safe alternative to ERCP in MDBO. An almost nonexistent risk of procedure-related pancreatitis, lower procedure time, and ease of use make this an attractive primary approach to biliary decompression in centers with expertise.

Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs.

METHODS

Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models.

RESULTS

The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events.

CONCLUSIONS

EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.

Efficacy of scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis

Background

Endoscopic submucosal dissection (ESD) is an effective resection technique for early cancers and large gastrointestinal luminal lesions. However, ESD is technically challenging, with the potential for severe adverse events. Scissor-type ESD (ST-ESD) knives with an inner cutting edge and an electrically insulated external coating could mitigate some of these risks. This study aimed to evaluate the performance of ST electrosurgical knives when used for ESDs.

Methods

Electronic databases were queried for studies from January 2005 through December 2022 evaluating the performance of ST-ESD knives. Fixed- and random-effects models were used to calculate pooled proportions. Heterogeneity was assessed using the I2 test and by constructing funnel plots, while bias was calculated using Egger and Harbord bias indicators.

Results

Final analysis included data from 17 studies comprising 1652 ESD procedures. The pooled en bloc resection rate and R0 resection rate were 97.94% (95% confidence interval [CI] 97.20-98.57) and 94.32% (95%CI 93.11-95.43), respectively. The main adverse events were perforation and delayed post-procedural bleeding, with pooled rates of 1.07% (95%CI 0.63-1.62) and 1.86% (95%CI 1.26-2.56), respectively. There was no heterogeneity, as indicated by an I2 score of 0% (95%CI 0-44.50%). The mean procedure time was 67.45 min (95%CI 58.01-76.89).

Conclusions

Our analysis shows that ST-ESD knives deliver consistently good performance across various locations in the gastrointestinal lumen and lesion sizes, with a good safety profile. This could be particularly appealing to newer adopters of ESD.

Efficacy and Safety of Peroral Endoscopic Myotomy (POEM) in Achalasia: An Updated Meta-analysis

Background: Heller myotomy has been considered the standard surgical treatment for patients with achalasia. Since the initiation of peroral endoscopic myotomy (POEM), it has represented an alternative for treating patients with achalasia. Over the years, numerous prospective and retrospective studies with POEM use for achalasia have been published. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia. Methods: Publications investigating the safety and efficacy of POEM in patients with achalasia were searched in Medline, Ovid Journals, Medline non-indexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects models. Results: The initial search identified 328 reference articles; of these, 34 relevant articles were selected and reviewed. Data was extracted from 20 studies (n=1753) which met the inclusion criteria. In pooled analysis, the clinical success of POEM at 3 months was 94% (95% CI=93-95). The pooled clinical success of POEM at 12 months was 91% (95% CI=90-92). The pooled rate of gastroesophageal reflux disease (GERD) was 21% (95% CI=19-23), esophagitis was reported in 16% (95% CI=15-18), pneumomediastinum in 4% (95% CI=3-6), cervical emphysema in 12% (95% CI=10-13), pneumoperitoneum in 8% (95% CI=7-10), pneumothorax in 5% (95% CI=4 - 6), pleural effusion in 3% (95% CI=2-3), post-operative bleeding in 4.29% (95% CI=1.91 -7.61) and aspiration pneumonia in 3.08% (95% CI=1.13-5.97) of the patients after POEM. Conclusion: This meta-analysis suggests that POEM is a highly effective and safe endoscopic treatment for patients with achalasia and a reasonable alternative to Heller myotomy.

Efficacy of self-assembling peptide in mitigating delayed bleeding after advanced endoscopic resection of gastrointestinal lesions: A meta-analysis

Background and study aims  Advanced endoscopic resection techniques carry a risk of delayed bleeding (DB). A novel fully synthetic self-assembling peptide (SAP) has shown promising results in mitigating this risk. In this meta-analysis, we evaluated all available data and analyzed the effectiveness of SAP in reducing DB after advanced endoscopic resection of gastrointestinal luminal lesions. Patients and methods  Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the use of SAP solution in patients undergoing advanced endoscopic resection of gastrointestinal lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results  The initial search identified 277 studies, of which 63 relevant articles were reviewed. The final analysis included data from six studies comprising 307 patients that met inclusion criteria. The pooled rate of DB was 5.73 % (95 % confidence interval [CI] = 3.42-8.59). Mean patient age was 69.40 years ± 1.82. The weighted mean size of resected lesions was 36.20 mm (95 % CI = 33.37-39.02). Endoscopic submucosal dissection was used in 72.69 % (95 % CI = 67.62-77.48), while endoscopic mucosal resection was used in 26.42 % (95 % CI = 21.69-31.44) of the procedures. Among the 307 patients, 36 % were on antithrombotic medications. No adverse events (AEs) were attributable to using SAP, with a pooled rate of 0.00 % (95 % CI = 0.00-1.49). Conclusions  SAP solution appears promising in reducing post-procedural DB after advanced endoscopic resection of high-risk gastrointestinal lesions with no reported AEs.

Prevalence of Osteoporosis in Cirrhosis: A Systematic Review and Meta-Analysis

The prevalence of osteoporosis in individuals with cirrhosis varies based on the diagnostic approach and etiology of the underlying liver disease. This systematic review aims to evaluate the prevalence of osteoporosis in individuals with cirrhosis. Electronic databases were searched for studies reporting the prevalence of osteoporosis among patients with cirrhosis. The primary outcome was the presence of osteoporosis, as determined by a dual-energy x-ray absorptiometry (DEXA) scan. Secondary outcomes were levels of biochemical markers of bone metabolism, including calcium, vitamin D, phosphorus, and parathormone (PTH) levels. A cohort of 836 patients from 10 studies was included in the final analysis. The pooled rate of osteoporosis was 14.80% (95% CI: 14.19-15.49). Pooled levels of biochemical markers of bone metabolism were as follows: calcium 9.09 mg/dL (95% CI: 8.73-9.45), 25-hydroxyvitamin D (25-OH vitamin D) 15.41 ng/mL (95% CI: 14.79-16.03), phosphorus 15.41 mg/dL (95% CI: 2.99-3.51), and PTH 26.58 pg/mL (95% CI: 25.45-27.71). Pooled levels of liver biochemistries were: bilirubin 3.04 mg/dL (95% CI: 2.84-3.25), aspartate aminotransferase (AST) 65.35 U/L (95% CI: 61.39-69.31), alanine aminotransferase (ALT) 50.17 U/L (95% CI: 46.18-54.10), alkaline phosphatase 133.31 U/L (95% CI: 124.89-141.73), and albumin 3.25 g/dL (95% CI: 3.05-3.45). Cirrhosis appears to be associated with an increased risk for osteoporosis, with a pooled prevalence of 15%. This can include men and individuals younger than 50 years of age, a cohort not typically considered to be at an increased risk of osteoporosis. Levels of 25-hydroxyvitamin D and insulin-like growth factor-1 (IGF-1) were also significantly low. Further studies are required to evaluate the risk of osteoporosis based on the etiology and stage of cirrhosis, especially in younger males, to incorporate this into future prediction models for fragility fractures.

Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS : Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique. METHODS : Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events. RESULTS : Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08). CONCLUSIONS : Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis

BACKGROUND

Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.

AIM

To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events.

METHODS

We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI).

RESULTS

We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95).

CONCLUSION

Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Utility of Cyst Fluid Carcinoembryonic Antigen in Differentiating Mucinous and Non-mucinous Pancreatic Cysts: An Updated Meta-Analysis

BACKGROUND

Mucinous pancreatic cysts are considered premalignant and managed differently compared to benign pancreatic cystic lesions. The aim of this updated meta-analysis is to assess the diagnostic accuracy of cyst carcinoembryonic antigen (CEA) in differentiating between mucinous and non-mucinous pancreatic cysts.

METHODS

Studies comparing the diagnostic accuracy of CEA (cutoff level of 192 ng/mL) in differentiating between mucinous and non-mucinous pancreatic cysts were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooled estimates of diagnostic precision were calculated using random and fixed effects models.

RESULTS

Initial search identified 526 reference articles, of these 34 relevant articles were selected and reviewed. Data were extracted from 15 studies (n = 2063) which met the inclusion criteria. The pancreatic cystic fluid CEA level at a 192 ng/mL cutoff value had pooled specificity of 88.6% (95% CI 85.9-90.9) and pooled sensitivity was found to be 60.4% (95% CI 57.7-62.9). The pooled positive likelihood ratio was 4.5 (95% CI 2.9-6.9) and the pooled negative likelihood ratio was 0.45 (95% CI 0.38-0.52). The pooled diagnostic odds ratio, the odds of having mucinous cyst with elevated CEA, was 11.4 (95% CI 6.9-18.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSIONS

This meta-analysis suggests that the cyst fluid CEA level at a 192 ng/mL cutoff value is highly specific in the diagnosis of mucinous cystic lesions with reasonable sensitivity.

Adverse events in fecal microbiota transplantation: a systematic review and meta-analysis

Background

Methods

Results

Conclusions

Efficacy and safety of endoscopic transpapillary gallbladder drainage in acute cholecystitis: An updated meta-analysis

BACKGROUND

Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery. Endoscopic transpapillary gallbladder drainage (ETGBD) has evolved into an alternative treatment. There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis, though results have been variable.

AIM

To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis.

METHODS

We performed a systematic review of major literature databases including PubMed, OVID, Science Direct, Google Scholar (from inception to March 2021) to identify studies reporting technical and clinical success, and post procedure adverse events in ETGBD. Weighted pooled rates were then calculated using fixed effects models for technical and clinical success, and post procedure adverse events, including recurrent cholecystitis.

RESULTS

We found 21 relevant articles that were then included in the study. In all 1307 patients were identified. The pooled technical success rate was 82.62% [95% confidence interval (CI): 80.63-84.52]. The pooled clinical success rate was found to be 94.87% (95%CI: 93.54-96.05). The pooled overall complication rate was 8.83% (95%CI: 7.42-10.34). Pooled rates of post procedure adverse events were bleeding 1.03% (95%CI: 0.58-1.62), perforation 0.78% (95%CI: 0.39-1.29), peritonitis/bile leak 0.45% (95%CI: 0.17-0.87), and pancreatitis 1.98% (95%CI: 1.33-2.76). The pooled rates of stent occlusion and migration were 0.39% (95%CI: 0.13-0.78) and 1.3% (95%CI: 0.75-1.99) respectively. The pooled rate of cholecystitis recurrence following ETGBD was 1.48% (95%CI: 0.92-2.16).

CONCLUSION

Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review

Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis.

Methods:

Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran’s Q test based upon inverse variance weights. 

Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68–74). Bias calculated using Begg–Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61–71) and 57% (95% CI = 48–67), respectively.

Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.

Early vs late cholecystectomy in mild gall stone pancreatitis: An updated meta-analysis and review of literature

BACKGROUND

Gallstone pancreatitis is one of the most common causes of acute pancreatitis. Cholecystectomy remains the definitive treatment of choice to prevent recurrence. The rate of early cholecystectomies during index admission remains low due to perceived increased risk of complications.

AIM

To compare outcomes including length of stay, duration of surgery, biliary complications, conversion to open cholecystectomy, intra-operative, and post-operative complications between patients who undergo cholecystectomy during index admission as compared to those who undergo cholecystectomy thereafter.

METHODS

Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model).

RESULTS

Initial search identified 163 reference articles, of which 45 were selected and reviewed. Eighteen studies (n = 2651) that met the inclusion criteria were included in this analysis. Median age of patients in the late group was 43.8 years while that in the early group was 43.6. Pooled analysis showed late laparoscopic cholecystectomy group was associated with an increased length of stay by 88.96 h (95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled risk difference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group. Pooled analysis showed no risk difference in intraoperative complications [risk difference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [risk difference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy [risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and late cholecystectomy groups. Pooled analysis showed the duration of surgery to be prolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy group as compared to the early group.

CONCLUSION

In patients with mild gallstone pancreatitis early cholecystectomy leads to shorter hospital stay, shorter duration of surgery, while decreasing the risk of biliary complications. Rate of intraoperative, post-operative complications and chances of conversion to open cholecystectomy do not significantly differ whether cholecystectomy was performed early or late.

Split-dose vs same-day bowel preparation for afternoon colonoscopies: A meta-analysis of randomized controlled trials

BACKGROUND

Quality of bowel preparation in afternoon colonoscopies has been a struggle. Currently, a choice of same-day preparation (SaD) or split-dose preparation (SpD) exists; however, randomized controlled trials’ results have varied. 

AIM

To examine the outcomes of SaD and SpD for afternoon colonoscopies.

METHODS

An extensive literature search was conducted using multiple databases. Only randomized controlled trials (RCTs) in adults that compared SaD to SpD with Ottawa bowel preparation score (OBPS) were included. Odds ratio (OR) or mean difference was used to analyze outcomes.

RESULTS

Eleven RCTs were included (n = 1846). No difference was observed for satisfactory bowel preparation based on OBPS among participants receiving SaD vs SpD (OR 0.77; 95%CI: -0.57-1.03; P = 0.07; I² = 5%). Subgroup analysis showed no difference in terms of satisfactory bowel preparation based on OBPS between the two groups when receiving same preparation formula (polyethylene glycol) (OR 0.83; 95%CI: 0.51-1.35; P = 0.46; I² = 39%) as well as receiving same formula and volume (4 L polyethylene glycol) (OR 1.14; 95%CI: 0.65-2.01; P = 0.64; I² = 0%).

CONCLUSION

In patients undergoing afternoon colonoscopies, SaD is comparable with SpD in terms of satisfactory bowel preparation. Further studies are needed to validate these results and determine the optimal formula and dosages.

Endoscopic ultrasound-guided fiducial marker placement in pancreatic cancer: A systematic review and meta-analysis

BACKGROUND

Pancreatic cancer (PC) mortality remains high despite advances in therapy. Combination chemoradiotherapy offers modest survival benefit over monotherapy with either. Fiducial markers serve as needed landmarks for image-guided radiotherapy (IGRT). Traditionally, these markers were placed surgically or percutaneously with limitations of each. Endoscopic ultrasound-guided placement overcomes these limitations.

AIM

To evaluate the safety, efficacy, and feasibility of endoscopic ultrasound (EUS)-guided fiducial placement for PC undergoing IGRT.

METHODS

Articles were searched in MEDLINE, PubMed, and Ovid journals. Pooling was conducted by fixed and random effects models. Heterogeneity was assessed using Cochran’s Q test based upon inverse variance weights.

RESULTS

Initial search identified 1024 reference articles for EUS-guided fiducial placement in PC. Of these, 261 relevant articles were reviewed. Data was extracted from 11 studies (n = 820) meeting inclusion criteria. Pooled proportion of successful placement was 96.27% (95%CI: 95.35-97.81) with fiducial migration rates low at 4.33% (95%CI: 2.45-6.71). Adverse event rates remained low, with overall pooled proportion of 4.85% (95%CI: 3.04-7.03).

CONCLUSION

EUS-guided placement of fiducial markers for IGRT of PC is safe, feasible, and efficacious. The ability to target deep structures under direct visualization while remaining minimally invasive are added benefits. Moreover, the ability to perform fine needle aspiration or celiac plexus neurolysis add value and increase patient-care efficiency. Whether EUS-guided fiducial placement improves outcomes in IGRT or offers any mortality benefits over traditional placement remains unknown and future studies are needed.

Use of music during colonoscopy: An updated meta-analysis of randomized controlled trials

BACKGROUND

Music seems to be beneficial in multiple clinical areas. Colonoscopy is a stressful event for patients, especially with conscious sedation. Music during colonoscopy has been evaluated in multiple randomized controlled trials (RCTs) with varied results. Even meta-analyses on the subject over the years have yielded inconsistent conclusions. Therefore, we conducted an up-to-date meta-analysis regarding music during colonoscopy.

AIM

To assess the effects of music played during colonoscopy on patients’ perspectives and sedation requirements.

METHODS

Multiple large databases were aggressively searched (November 2018). RCTs comparing music to without music during colonoscopy on adult patients were included. Pooled estimates were calculated for sedative medication doses, total procedure time, and patients’ experience, willingness to repeat procedure, and pain scores using odds ratio (OR) and mean difference (MD) with random effects model.

RESULTS

Eleven studies (n = 988) were included. Music during colonoscopy showed a statistically significant reduction in procedure times (MD: -2.3 min; 95%CI: -4.13 to -0.47; P = 0.01) and patients’ pain (MD: -1.26; 95%CI: -2.28 to -0.24; P = 0.02) while improving patients’ experience (MD: -1.11; 95%CI: -1.7 to -0.53; P < 0.01) as compared to no music. No statistically significant differences were observed between music and no music during colonoscopy for midazolam (MD: -0.4 mg; 95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg; 95%CI: -10.79 to 4.67; P = 0.44), or patients’ willingness to repeat the colonoscopy (OR: 3.89; 95%CI: 0.76 to 19.97; P = 0.1).

CONCLUSION

Music appears to improve overall patient experience while reducing procedure times and patient pain. Therefore, music, being a non-invasive intervention, should be strongly considered during colonoscopy.

Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials

Background:

In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results.

Methods:

Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models.

Results:

Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively).

Conclusions:

The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

Is there a difference between 19G core biopsy needle and 22G core biopsy needle in diagnosing the correct etiology? - A meta-analysis and systematic review

AIM

To compare the accuracy of endoscopic ultrasonography (EUS) 19G core biopsies and 22G core biopsies in diagnosing the correct etiology for a solid mass.

METHODS

Articles were searched in Medline, PubMed, and Ovid journals. Pooling was conducted by both fixed and random effects models.

RESULTS

Initial search identified 4460 reference articles for 19G and 22G, of these 670 relevant articles were selected and reviewed. Data was extracted from 6 studies for 19G (n = 289) and 16 studies for 22G (n = 592) which met the inclusion criteria. EUS 19G core biopsies had a pooled sensitivity of 91.6% (95%CI: 87.1-95.0) and pooled specificity of 95.9% (95%CI: 88.6-99.2), whereas EUS 22G had a pooled sensitivity of 83.3% (95%CI: 79.7-86.6) and pooled specificity of 64.3% (95%CI: 54.7-73.1). The positive likelihood ratio of EUS 19G core biopsies was 9.08 (95%CI: 1.12-73.66) and EUS 22G core biopsies was 1.99 (95%CI: 1.09-3.66). The negative likelihood ratio of EUS 19G core biopsies was 0.12 (95%CI: 0.07-0.24) and EUS 22G core biopsies was 0.25 (95%CI: 0.14-0.41). The diagnostic odds ratio was 84.74 (95%CI: 18.31-392.26) for 19G core biopsies and 10.55 (95% CI: 3.29-33.87) for 22G needles.

CONCLUSION

EUS 19G core biopsies have an excellent diagnostic value and seem to be better than EUS 22G biopsies in detecting the correct etiology for a solid mass.

Role of endoscopic esophageal dilation in managing eosinophilic esophagitis: A systematic review and meta-analysis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder of the esophagus characterized by mucosal eosinophilic infiltration. Topical glucocorticoids are considered standard line of treatment, whereas endoscopic dilations are performed for patients presenting with treatment-resistant disease or manifestations of dysphagia and/or food impactions. Efficacy and safety of esophageal dilation in these patients are currently unclear.

AIMS

Primary outcomes were to evaluate the efficacy, adverse events, and mortality rates of endoscopic esophageal dilation in patients with EoE.

METHODS

STUDY SELECTION CRITERIA:: Studies that reported the use of esophageal dilation in EoE patients were included in this meta-analysis.

DATA COLLECTION AND EXTRACTION

Articles were searched in Medline, Pubmed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA statement. Clinical improvement was defined as patient-reported symptom relief noted by the authors of individual studies. The symptoms were assessed on various nonstandardized, however, relevant questionnaires that were deemed appropriate by the senior authors of individual studies.

STATISTICAL METHOD

Pooled proportions were calculated using fixed- and random-effects model. I statistic was used to assess heterogeneity among studies.

RESULTS

Initial search identified 491 reference articles, in which 39 articles were selected and reviewed. Data were extracted from 14 studies (N = 1607) using esophageal dilation for EoE management, which met the inclusion criterion. Mean age of patients was 41years. Pooled patients included 75% males. The pooled proportion of patients that showed clinical improvement with esophageal dilations, after the median follow-up period of 12 months, was 84.95%. No procedure-related deaths were noted. The pooled proportion of patients with post procedural esophageal perforation, chest pain, hospitalization, deep mucosal tear (involving muscularis propria), small mucosal tear, and hemorrhage were 0.61%, 0.06%, 0.74%, 4.04%, 22.32%, and 0.38% respectively. I (inconsistency) was 0% (95% confidence interval [CI] = 0-49.8) and Egger: bias was 0.06 (95% CI = -0.30 to 0.42).

CONCLUSIONS

In patients with conformed diagnosis of EoE, endoscopic esophageal dilation seems to be an effective and safe treatment option. Majority patients with chest pain and deep mucosal tears did not require hospitalization and symptoms were self-limiting.

A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP

BACKGROUND

In patients with inoperable malignant biliary strictures, endoscopic retrograde cholangiopancreatography (ERCP) guided biliary stenting fails in 5% to 10% patients due to difficult anatomy/inability to cannulate the papilla. Recently, endoscopic ultrasound guided biliary drainage (EUS-BD) has been described.Primary outcomes were to evaluate the biliary drainage success rates with EUS and compare it to percutaneous transhepatic biliary drainage (PTBD). Secondary outcomes were to evaluate overall procedure related complications.

METHODS

STUDY SELECTION CRITERIA:: Studies evaluating the efficacy of EUS-BD and comparing EUS-BD versus PTBD in inoperable malignant biliary stricture patients with a failed ERCP were included in this analysis.

DATA COLLECTION AND EXTRACTION

Articles were searched in Medline, PubMed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Subgroup analyses of prospective studies and EUS-BD versus PTBD were performed.

STATISTICAL METHOD

Pooled proportions were calculated using fixed and random effects model. I statistic was used to assess heterogeneity among studies.

RESULTS

Initial search identified 846 reference articles, of which 124 were selected and reviewed. Sixteen studies (N = 528) that met the inclusion criteria were included in this analysis. In the pooled patient population, the percentage of patients that had a successful biliary drainage with EUS was 90.91% (95% CI = 88.10-93.38). The proportion of patients that had overall procedure related complications with EUS-PD was 16.46% (95% CI = 13.20-20.01). The pooled odds ratio for successful biliary drainage in EUS-PD versus PTBD group was 3.06 (95% CI = 1.11-8.43). The risk difference for overall procedure related complications in EUS-PD versus PTBD group was -0.21 (95% CI = -0.35 to -0.06). Relative risk for infectious complications and bile leak in EUS-BD versus PTBD was 0.25 (95% CI = 0.07-0.94) and 0.33 (95% CI = 0.12-0.87), respectively.

CONCLUSIONS

In patients with inoperable malignant biliary strictures who failed an ERCP guided biliary stenting, EUS-BD seems to be an excellent management option and superior to PTBD with higher successful biliary drainage rates and relatively fewer complications.

Irritable Bowel Syndrome: A Clinical Review

Symptoms of irritable bowel syndrome (IBS) are common in population studies including chronic abdominal pain associated with altered bowel habits. Patients often have associated gastrointestinal and somatic symptoms suggesting a possible common contributing mechanism, but the heterogeneous symptom patterns of individual patients make generalizations difficult. The pathophysiology of IBS is incompletely understood but includes disturbances of the brain-gut axis. Central mechanisms are: the psychosocial history and environment, dysfunctional brain processing of peripheral signals attributed to the intestine including the enteric nervous system, the microbiome and the innate and adaptive immune system. As a result there is visceral hypersensitivity and disturbed intestinal secretory and motor activity. Some mechanisms of visceral pain hypersensitivity may overlap with other pain syndromes including fibromyalgia (FMS). Central Sensitization (CS) would offer a way to conceptualize an integration of life experience and psychologic response into a biopsychosocial framework of pathophysiology, diagnosis and treatment of IBS. Corticotropin-releasing factor, a principle regulator in the stress and pain response may contribute to a neuroendocrine mechanism for the brain-gut interaction. The positive diagnostic approach to IBS symptoms to avoid excess testing and enhance the patient-provider therapeutic relationship requires the recognition of the "cluster" of IBS symptoms while identifying "alarm" symptoms requiring specific attention. The severity of the symptoms and other individual psychosocial factors characterize patients who seek medical care. The presence of significant psychosocial comorbidities adds to the complexity of management which often requires a multidisciplinary approach. Several treatment options exist but no single method is effective for all the symptoms of IBS. The therapeutic benefit of the well-executed physician-patient relationship is considered essential to success in managing IBS symptoms over the long term.

Covered versus uncovered self-expandable metal stents for malignant biliary strictures: A meta-analysis and systematic review

Self-expandable metal stents (SEMS) are used for palliating inoperable malignant biliary strictures. It is unclear if covered metal stents are superior to uncovered metal stents in these patients. We compared clinical outcomes in patients with covered and uncovered stents. Studies using covered and uncovered metallic stents for palliation in patients with malignant biliary stricture were reviewed. Articles were searched in MEDLINE, PubMed, and Ovid journals. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1436 reference articles, of which 132 were selected and reviewed. Thirteen studies (n = 2239) for covered and uncovered metallic stents which met the inclusion criteria were included in this analysis. Odds ratio for stent occlusion rates in covered vs. uncovered stents was 0.79 (95 % CI = 0.65 to 0.96). Survival benefit in patients with covered vs. uncovered stents showed the odds ratio to be 1.29 (95 % CI = 0.95 to 1.74). Pooled odds ratio for migration of covered vs. uncovered stents was 9.9 (95 % CI = 4.5 to 22.3). Covered stents seemed to have significantly lesser occlusion rates, increased odds of migration, and increased odds of pancreatitis compared to uncovered stents. There was no statistically significant difference in the survival benefit, overall adverse event rate, and patency period of covered vs. uncovered metal stents in patients with malignant biliary strictures.

Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review

BACKGROUND

Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding.

METHODS

Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip.

RESULTS

Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56-4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42-1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69-2.24; P=0.47) were analyzed.

CONCLUSIONS

The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.

Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review

BACKGROUND

In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by restoration of biliary flow prior to operation. This is a meta-analysis to pool the evidence and assess the utility of PBD in patients with malignant obstructive jaundice. The primary outcome is comparing mortality outcomes in patients with malignant obstructive jaundice undergoing direct surgery (DS) versus PBD. The secondary outcomes include major adverse events and length of hospital stay in both the groups.

METHODS

Studies using PBD in patients with malignant obstructive jaundice were included in this study. For the data collection and extraction, articles were searched in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, etc. Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model).

RESULTS

Initial search identified 2230 reference articles, of which 204 were selected and reviewed. Twenty-six studies (N = 3532) for PBD in malignant obstructive jaundice which met the inclusion criteria were included in this analysis. The odds ratio for mortality in PBD group versus DS group was 0.96 (95 % CI = 0.71 to 1.29). Pooled number of major adverse effects was lower in the PBD group at 10.40 (95 % CI = 9.96 to 10.83) compared to 15.56 (95 % CI = 15.06 to 16.05) in the DS group. Subgroup analysis comparing internal PBD to DS group showed lower odds for major adverse events (odds ratio, 0.48 with 95 % CI = 0.32 to 0.74).

CONCLUSIONS

In patients with malignant biliary jaundice requiring surgery, PBD group had significantly less major adverse effects than DS group. Length of hospital stay and mortality rate were comparable in both the groups.

Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review

Background

In patients suffering from upper gastrointestinal bleeding (UGIB), adequate visualization is essential during endoscopy. Prior to endoscopy, erythromycin administration has been shown to enhance visualization in these patients; however, guidelines have not fully adopted this practice. Thus, we performed a comprehensive, up-to-date meta-analysis on the issue of erythromycin administration in this patient population.

Methods

After searching multiple databases (November 2015), randomized controlled trials on adult subjects comparing administration of erythromycin before endoscopy in UGIB patients to no erythromycin or placebo were included. Pooled estimates of adequacy of gastric mucosa visualized, need for second endoscopy, duration of procedure, length of hospital stay, units of blood transfused, and need for emergent surgery using odds ratio (OR) or mean difference (MD) were calculated. Heterogeneity and publication bias were assessed.

Results

Eight studies (n=598) were found to meet the inclusion criteria. Erythromycin administration showed statistically significant improvement in adequate gastric mucosa visualization (OR 4.14; 95% CI: 2.01-8.53, P<0.01) while reduced the need for a second-look endoscopy (OR 0.51; 95% CI: 0.34-0.77, P<0.01) and length of hospital stay (MD -1.75; 95% CI: -2.43 to -1.06, P<0.01). Duration of procedure (P=0.2), units of blood transfused (P=0.08), and need for emergent surgery (P=0.88) showed no significant differences.

Conclusion

Pre-endoscopic erythromycin administration in UGIB patients significantly improves gastric mucosa visualization while reducing length of hospital stay and the need for second-look endoscopy.

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Low-residue versus clear liquid diet before colonoscopy: a meta-analysis of randomized, controlled trials

BACKGROUND AND AIMS

Colonoscopy is extremely important for the identification and removal of precancerous polyps. Bowel preparation before colonoscopy is essential for adequate visualization. Traditionally, patients have been instructed to consume only clear liquids the day before a colonoscopy. However, recent studies have suggested using a low-residue diet, with varying results. We evaluated the outcomes of patients undergoing colonoscopy who consumed a clear liquid diet (CLD) versus low-residue diet (LRD) on the day before colonoscopy by a meta-analysis.

METHODS

Scopus, PubMed/MEDLINE, Cochrane databases, and CINAHL were searched (February 2015). Studies involving adult patients undergoing colonoscopy examination and comparing LRD with CLD on the day before colonoscopy were included. The analysis was conducted by using the Mantel-Haenszel or DerSimonian and Laird models with the odds ratio (OR) to assess adequate bowel preparations, tolerability, willingness to repeat diet and preparation, and adverse effects.

RESULTS

Nine studies (1686 patients) were included. Patients consuming an LRD compared with a CLD demonstrated significantly higher odds of tolerability (OR 1.92; 95% CI, 1.36-2.70; P < .01) and willingness to repeat preparation (OR 1.86; 95% CI, 1.34-2.59; P < .01) with no differences in adequate bowel preparations (OR 1.21; 95% CI, 0.64-2.28; P = .58) or adverse effects (OR 0.88; 95% CI, 0.58-1.35; P = .57).

CONCLUSION

An LRD before colonoscopy resulted in improved tolerability by patients and willingness to repeat preparation with no differences in preparation quality and adverse effects.

Oral clindamycin causing acute cholestatic hepatitis without ductopenia: a brief review of idiosyncratic drug-induced liver injury and a case report

Clindamycin is a lincosamide antibiotic active against most of the anaerobes, protozoans, and Gram-positive bacteria, including community-acquired methicillin-resistant Staphylococcus aureus. Its use has increased greatly in the recent past due to wide spectrum of activity and good bioavailability in oral form. Close to 20% of the patients taking clindamycin experience diarrhea as the most common side effect. Hepatotoxicity is a rare side effect. Systemic clindamycin therapy has been linked to two forms of hepatotoxicity: transient serum aminotransferase elevation and an acute idiosyncratic liver injury that occurs 1–3 weeks after starting therapy. This article is a case report of oral clindamycin induced acute symptomatic cholestatic hepatitis and a brief review of the topic.

Success of endoscopic ultrasound-guided ethanol ablation of pancreatic cysts: a meta-analysis and systematic review

BACKGROUND

Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts.

METHOD STUDY SELECTION CRITERIA

EUS-guided ethanol ablation of pancreatic cysts.

DATA COLLECTION EXTRACTION

Articles were searched in Medline, Pubmed, and Ovid journals.

STATISTICAL METHOD

Fixed and random effects models were used to calculate the pooled proportions.

RESULTS

Initial search identified 1,319 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from seven studies (n = 152) of EUS-guided ethanol ablation of pancreatic cysts, which met the inclusion criteria. With EUS-guided ethanol ablation, the pooled proportion of patients with complete cyst resolution was 56.20 % (95 % CI = 48.16 to 64.08) and partial cyst resolution was 23.72 % (95 % CI = 17.24 to 30.89). Postprocedural complications after ablation were significant for abdominal pain in 6.51 % (95 % CI = 3.12 to 11.04) and pancreatitis in 3.90 % (95 % CI = 1.39 to 7.60) of the pooled percentage of patients. Publication bias calculated using Harbord-Egger bias indicator gave a value of -1.09 (95 % CI = 10.21 to 8.03, p = 0.77). The Begg-Mazumdar indicator gave a Kendall's tau b value of 0.05 (p ≥ 0.99).

CONCLUSIONS

EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intraprocedural and postprocedural complications. However, due to the limited data available, prospective randomized controlled trials with a long follow up period are required in this area.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy.

METHODS: MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency.

RESULTS: Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%.

CONCLUSION: Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

Endoscopic transmural necrosectomy for walled-off pancreatic necrosis: a systematic review and meta-analysis

BACKGROUND

Endoscopic transmural necrosectomy (ETN) is emerging as a viable treatment option for walled-off pancreatic necrosis. This NOTES-type procedure is significantly less invasive than an extensive surgical debridement; however, published data regarding the success of ETN in treating pancreatic necrosis have varied.

OBJECTIVE

To evaluate the published medical literature to determine the success of treating walled-off pancreatic necrosis with ETN.

METHODS

Studies using ETN as a primary mode of therapy to treat organized pancreatic necrosis were selected. Success was defined as resolution of the necrotic cavity proven by radiology. Articles were searched in Medline, PubMed, Ovid journals, CINAH, old Medline, Medline nonindexed citations and the Cochrane controlled trials registry. The summary estimates were expressed as pooled proportions. First, the individual study proportions were transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion was calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model. Publication bias was calculated using the Begg-Mazumdar and Harbord bias estimators.

RESULTS

The initial search identified 920 reference articles, of which 129 relevant articles were selected and reviewed. Data were extracted from eight studies (n=233) that met the inclusion criteria. Organization of pancreatic necrosis was determined by computed tomography scan in all of the studies. The mean time of ETN after onset of acute pancreatitis⁄abdominal pain was seven weeks. The weighted mean size of the necrotic cavity was 12.87 cm (95% CI 10.54 cm to 15.20 cm). The weighted mean number of endoscopic procedures needed to resolve the necrotic cavity was 4.09 (95% CI 2.31 to 5.87). Pooled proportion of successful resolution of pancreatic necrosis using ETN was 81.84% (95% CI 76.73% to 86.44%). The pooled proportion of recurrence in the form of necrotic cavity or pseudocyst after ETN was 10.88% (95% CI 7.27% to 15.11%). Complications were noted in 21.33% (95% CI 16.40% to 26.72%) of patients and included bleeding, sepsis and perforation. The weighted mean number of days in hospital after ETN was 32.85 days (95% CI 10.50 to 55.20 days). For pancreatic necrosis that did not resolve, surgery had to be performed in 12.98% (95% CI 9.05% to 17.51%) of patients. The fixed-effect model was used to report all of the pooled proportions. Estimates calculated using fixed- and random-effects models were similar. Test of heterogeneity yielded P>0.10, indicating that the studies could be combined. The publication bias calculated using Begg-Mazumdar bias indicator yielded a Kendall's tau b value of -0.07 (P=0.72) and the same using Harbord bias indicator gave a value of 0.33 (95% CI -1.35 to 2.01; P=0.60). Both of these indicators show that there was no publication bias.

CONCLUSION

The present meta-analysis showed that ETN is safe and effective at treating patients with symptomatic walled-off necrosis. ETN offers the advantage of minimally invasive endoscopic treatment without transabdominal surgery; however, better techniques and equipment are still needed to improve procedural efficiency. Decisions to perform ETN should be made by advanced endoscopists in collaboration with a multidisciplinary team with the facilities and personnel to manage these complex patients.

Bilateral and unilateral stenting for malignant hilar obstruction: a systematic review and meta-analysis

BACKGROUND

Stents are used for palliating inoperable malignant bile duct hilar obstruction. It is not clear if bilateral stenting provides any advantage over unilateral stenting in these patients. Compare bilateral and unilateral stenting in malignant hilar obstruction.

STUDY SELECTION CRITERIA

Studies using stents for palliation in patients with malignant hilar obstruction were selected.

DATA COLLECTION AND EXTRACTION

Articles were searched in MEDLINE, PubMed, Ovid journals, CINAH, International Pharmaceutical Abstracts, OLDMEDLINE, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement.

STATISTICAL METHODS

Pooled proportions were calculated using both the Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. The initial search identified 1,640 reference articles, of which 169 were selected and reviewed. Thirteen studies (n = 340) for bilateral metallic stents, eight studies (n = 575) for unilateral metallic stents, eight studies (n = 367) for bilateral plastic stenting, and seven studies (n = 850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in Tables 1 and 2. The pooled estimates by the fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. Bilateral metal stenting seems to have lower odds of overall complications when compared to unilateral metallic stenting. Bilateral metal stents seem to have higher odds of lowering bilirubin than unilateral metal stents, but the 30-day mortality was no different. For metal stents, bilateral metal stents are superior in palliating symptoms due to hyperbilirubinemia. Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30-day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events.

Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: a systematic review and meta analysis

AIM

To detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs.

METHODS

Only EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model).

RESULTS

Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION

EUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.

Ascorbic acid and low-volume polyethylene glycol for bowel preparation prior to colonoscopy: A meta-analysis

AIM: To evaluate the benefits of low-volume polyethylene glycol (PEG) with ascorbic acid compared to full-dose PEG for colonoscopy preparation.

METHODS: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, CINAHL, PubMed, and recent abstracts from major conferences were searched (January 2012). Only randomized-controlled trials on adult subjects comparing low-volume PEG (2 L) with ascorbic acid vs full-dose PEG (3 or 4 L) were included. Meta-analysis for the efficacy of low-volume PEG with ascorbic acid and full-dose PEG were analyzed by calculating pooled estimates of number of satisfactory bowel preparations as well as adverse patient events (abdominal pain, nausea, vomiting). Separate analyses were performed for each main outcome by using OR with fixed and random effects models. Heterogeneity was assessed by calculating the I² measure of inconsistency. RevMan 5.1 was utilized for statistical analysis.

RESULTS: The initial search identified 242 articles and trials. Nine studies (n = 2911) met the inclusion criteria and were analyzed for this meta-analysis with mean age range from 53.0 to 59.6 years. All studies were randomized controlled trials on adult patients comparing large-volume PEG solutions (3 or 4 L) with low-volume PEG solutions and ascorbic acid. No statistically significant difference was noted between low-volume PEG with ascorbic acid and full-dose PEG for number of satisfactory bowel preparations (OR 1.07, 95%CI: 0.86-1.33, P = 0.56). No statistically significant difference was noted between low-volume PEG with ascorbic acid and full-dose PEG for abdominal pain (OR 1.09, 95%CI: 0.81-1.48, P = 0.56), nausea (OR 0.70, 95%CI: 0.49-1.00, P = 0.05), or vomiting (OR 0.99, 95%CI: 0.78-1.26, P = 0.95). No publication bias was noted.

CONCLUSION: Low-volume PEG with the addition of ascorbic acid demonstrates no statistically significant difference to full-dose PEG for satisfactory bowel preparation and side-effects.

Warfarin Use During Fecal Occult Blood Testing: A Meta-Analysis

Background

Fecal occult blood testing (FOBT) is a widely used screening test for colorectal cancer (CRC). Given the limited data about the effects of warfarin on FOBT are inconclusive, current screening guidelines for CRC do not address whether warfarin should be discontinued before FOBT. Therefore, we conducted a meta-analysis to evaluate the influence of warfarin on the yield of FOBT.

Methods

Multiple medical databases were searched (April 2011). Studies examining the use of warfarin versus no warfarin for FOBT were included. Meta-analysis for the effect of warfarin or no warfarin for FOBT was performed by calculating pooled estimates of colonoscopy findings and detection of neoplasia, any adenoma, advanced adenoma, or colon cancer by odds ratio (OR) with fixed and random effects model. RevMan 5.1 was utilized for statistical analysis.

Results

Five studies (N = 11,244) met the inclusion criteria. No statistically significant difference was noted between FOBT with or without warfarin for colonoscopy findings (OR 0.88; 95% CI: 0.48 - 1.62, P = 0.67) or detection of neoplasia (OR 0.88; 95% CI: 0.58 - 1.35, P = 0.57), any adenoma (OR 1.08; 95% CI: 0.73 - 1.58, P = 0.71), advanced adenoma (OR 1.07; 95% CI: 0.69 - 1.65, P = 0.78), and colon cancer (OR 0.69; 95% CI: 0.38 - 1.23, P = 0.21).

Conclusions

Among patients with positive FOBT, the yield of colonoscopy appears not to be altered by warfarin use.

Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND

Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting.

OBJECTIVE

We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy.

DESIGN

Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models.

SETTING

Literature search.

PATIENTS

Per RCTs.

MAIN OUTCOME MEASUREMENTS

Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects.

RESULTS

Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P < .01) and willingness to repeat the same preparation (OR 1.76; 95% CI, 1.06-2.91; P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P < .01) compared with full-dose PEG.

LIMITATIONS

Limited number of studies.

CONCLUSIONS

The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

BACKGROUND

Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results.

OBJECTIVE

We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis.

DESIGN

MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency.

SETTING

Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis.

PATIENTS

Adult patients undergoing ERCP.

INTERVENTIONS

Pancreatic stent placement for the prevention of post-ERCP pancreatitis.

MAIN OUTCOME MEASUREMENTS

Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement.

RESULTS

Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies.

LIMITATIONS

Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement.

CONCLUSIONS

Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

The impact of pre-endoscopy proton pump inhibitor use on the classification of non-erosive reflux disease and erosive oesophagitis

BACKGROUND

Factors associated with non-erosive reflux disease (NERD) and erosive oesophagitis (EO) are incompletely understood and the overlap between the two entities is debated.

AIM

To compare clinical, demographic, and endoscopic findings in a large cohort of NERD and EO patients.

METHODS

After they completed a validated GERD questionnaire, patients who presented for index endoscopy were enrolled and categorized as NERD or EO. Analysis was performed using Chi-square, Mann-Whitney U-test and multivariate logistic regression.

RESULTS

A total of 696 GERD patients [455 (65.4%) NERD; 241 (34.6%) EO]; mean age 57 years; 92% men and 82% Caucasian were prospectively enrolled. Using logistic regression, patients on PPI were more likely to be classified as NERD (OR: 3.2; P < 0.001). NERD patients were older (OR: 1.50; P = 0.05), less likely to have nocturnal symptoms (OR: 0.63; P = 0.04) and hiatal hernia (OR: 0.32; P < 0.001). Compared with PPI-naïve NERD patients, those on PPI were more likely to have nocturnal symptoms (69% vs. 29%, P = 0.048) and less likely to have mild-moderate symptoms (63% vs. 79%, P < 0.001) - similar to the EO group.

CONCLUSIONS

Pre-endoscopy PPI usage contributes significantly to the classification of GERD patients into the NERD-phenotype. NERD patients on PPI therapy demonstrate some features that are significantly different from PPI-naïve patients, but similar to EO patients. This observation supports the notion that some PPI NERD patients are actually healed EO patients, and that an overlap does exist between the GERD phenotypes.

Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review

BACKGROUND

Rectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied.

AIM

To evaluate the accuracy of EUS in T0 staging of rectal cancers. METHOD (STUDY SELECTION CRITERIA): Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa. DATA COLLECTION AND EXTRACTION: Articles were searched in Medline, PubMed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both the fixed-effects model and random-effects model.

RESULTS

An initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (N = 1,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7-99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3-97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3-29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04-0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10.

CONCLUSIONS

EUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47-85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51-64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.

Meta-analysis and systematic review of colorectal endoscopic mucosal resection

AIM: To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection (EMR).

METHODS: Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources.

RESULTS: An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies (n = 5221) which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% (95% CI: 51.50-73.52). The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% (95% CI: 47.14-69.71). With higher patient load (> 200 patients), this complete cure en-bloc resection rate improves from 44.19% (95% CI: 24.31-65.09) to 69.17% (95% CI: 51.11-84.61).

CONCLUSION: EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.

Successful complete cure en-bloc resection of large nonpedunculated colonic polyps by endoscopic submucosal dissection: a meta-analysis and systematic review

BACKGROUND

Endoscopic submucosal dissection (ESD) has emerged as one of the techniques to successfully resect large colonic polyps en bloc. Complete resection prevents the patient from going through transabdominal colonic resection. We sought to evaluate the proportion of successful en-bloc and complete cure en-bloc resection of large colonic polyps by ESD.

METHODS

Studies that use ESD technique to resect large colonic polyps were selected. Successful en-bloc resection was defined as resection of the polyp in one piece. Successful complete cure en-bloc resection was defined as one piece with histologic disease-free-margin polyp resection. Articles were searched in Medline, PubMed, and Cochrane control trial registry. Pooled proportions were calculated by both fixed and random-effects model.

RESULTS

The initial search identified 2,120 reference articles; 389 relevant articles were selected and reviewed. Data were extracted from 14 studies (n = 1,314) that met the inclusion criteria. The mean +/- standard error size of the polyps was 30.65 +/- 2.88 mm. Pooled proportion of en-bloc resection by the random-effects model was 84.91% (95% confidence interval, 77.82-90.82) and complete cure en-bloc resection was 75.39% (95% confidence interval, 66.69-82.21). The fixed-effects model was not used because of the heterogeneity of studies.

CONCLUSIONS

ESD should be considered the best minimally invasive endoscopic technique in the treatment of large (>2 cm) sessile and flat polyps because it allows full pathological evaluation and cure in most patients. ESD offers an important alternative to surgery in the therapy of large sessile and flat polyps.

Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review

BACKGROUND

Nodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent.

AIM

To evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers.

METHOD

Study Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both fixed-effects model and random-effects model.

RESULTS

The initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (N = 2732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6-75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5-78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16-3.72), and negative likelihood ratio was 0.42 (95% CI 0.33-0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10.

CONCLUSIONS

EUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

Esophageal adenocarcinoma in Barrett's esophagus after endoscopic ablative therapy: a meta-analysis and systematic review

OBJECTIVES

The extent of reduction of esophageal adenocarcinoma (EAC) incidence in Barrett's esophagus (BE) patients after endoscopic ablation is not known. The objective of this study was to determine the cancer incidence in BE patients after ablative therapy and compare these rates to cohort studies of BE patients not undergoing ablation.

METHODS

A MEDLINE search of the literature on the natural history and ablative modalities in BE patients was performed. Patients with nondysplastic BE (NDBE), low-grade dysplasia (LGD), or high-grade dysplasia (HGD) and follow-up of at least 6 months were included. The rate of cancer in patients undergoing ablation and from the natural history data was calculated using weighted-average incidence rates (WIR).

RESULTS

A total of 53 articles met the inclusion criteria for the natural history data. Pooled natural history data showed cancer incidence of 5.98/1,000 patient-years (95% CI 5.05-6.91) in NDBE; 16.98/1,000 patient-years (95% CI 13.1-20.85) in LGD; and 65.8/1,000 patient-years (95% CI 49.7-81.8) in HGD patients. A total of 65 articles met the inclusion criteria for BE patients undergoing ablation (1,457 patients, NDBE; 239 patients, LGD; and 611 patients, HGD). The WIR for cancer was 1.63/1,000 patient-years (95% CI 0.07-3.34) for NDBE; 1.58/1,000 patient-years (95% CI 0.66-3.84) for LGD; and 16.76/1,000 patient-years (95% CI 10.6-22.9) for HGD patients.

CONCLUSIONS

Compared to historical reports of the natural history of BE, ablation may be associated with a reduction in cancer incidence, although such a comparison is limited by likely heterogeneity between treatment and natural history studies. The greatest benefit of ablation was observed in BE patients with HGD.

How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis

BACKGROUND

Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (< or = 4 h) after PEG placement.

METHODS

Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (< or = 4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death < or = 72 h, and significant increases in postprocedural gastric residual volume during day 1.

RESULTS

Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (< or = 4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47-1.58, P = 0.63) or death in < or = 72 h (OR 0.56, 95% CI 0.18-1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02-3.19, P = 0.04).

CONCLUSIONS

Early feeding < or = 4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.