HOT VERSUS COLD SNARE FOR COLORECTAL POLYPECTOMIES SIZED UP TO 10MM: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

Colorectal cancer is the third most common cancer, and prevention relies on screening programs with resection complete resection of neoplastic lesions.

OBJECTIVE

We aimed to evaluate the best snare polypectomy technique for colorectal lesions up to 10 mm, focusing on complete resection rate, and adverse events.

METHODS

A comprehensive search using electronic databases was conducted to identify randomized controlled trials comparing hot versus cold snare resection for polyps sized up to 10 mm, and following PRISMA guidelines, a meta-analysis was performed. Outcomes included complete resection rate, en bloc resection rate, polypectomy, procedure times, immediate, delayed bleeding, and perforation.

RESULTS

Nineteen RCTs involving 8720 patients and 17588 polyps were included. Hot snare polypectomy showed a higher complete resection rate (RD, 0.02; 95%CI [+0.00,0.04]; P=0.03; I 2=63%), but also a higher rate of delayed bleeding (RD 0.00; 95%CI [0.00, 0.01]; P=0.01; I 2=0%), and severe delayed bleeding (RD 0.00; 95%CI [0.00, 0.00]; P=0.04; I 2=0%). Cold Snare was associated with shorter polypectomy time (MD -46.89 seconds; 95%CI [-62.99, -30.79]; P<0.00001; I 2=90%) and shorter total colonoscopy time (MD -7.17 minutes; 95%CI [-9.10, -5.25]; P<0.00001; I 2=41%). No significant differences were observed in en bloc resection rate or immediate bleeding.

CONCLUSION

Hot snare polypectomy presents a slightly higher complete resection rate, but, as it is associated with a longer procedure time and a higher rate of delayed bleeding compared to Cold Snare, it cannot be recommended as the gold standard approach. Individual analysis and personal experience should be considered when selecting the best approach.

Cryotherapy versus radiofrequency ablation in the treatment of dysplastic Barrett's esophagus with or without early esophageal neoplasia: a systematic review and meta-analysis

BACKGROUND/AIMS

Radiofrequency ablation (RFA) is the first-line therapy for dysplastic Barrett's esophagus (BE). Therefore, cryotherapy has emerged as an alternative treatment option. This study aimed to compare the efficacies of these two techniques based on the rates of complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D). Adverse events and recurrence have also been reported.

METHODS

An electronic search was conducted using the Medline (PubMed), Embase, LILACS, and Google Scholar databases until December 2022. Studies were included comparing cryotherapy and RFA for treating dysplastic BE with or without early esophageal neoplasia. This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Three retrospective cohort studies involving 627 patients were included. Of these, 399 patients underwent RFA, and 228 were treated with cryotherapy. There was no difference in CE-IM (risk difference [RD], -0.03; 95% confidence interval [CI], -0.25 to 0.19; p=0.78; I2=86%) as well as in CE-D (RD, -0.03; 95% CI, -0.15 to 0.09; p=0.64; I2=70%) between the groups. The absolute number of adverse events was low, and there was no difference in the recurrence rate.

CONCLUSION

Cryotherapy and RFA were equally effective in treating dysplastic BE, with or without early esophageal neoplasia.

Endoscopic vs radiologic gastrostomy for enteral feeding: A systematic review and meta-analysis

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are minimally invasive techniques commonly used for prolonged enteral nutrition. Despite safe, both techniques may lead to complications, such as bleeding, infection, pain, peritonitis, and tube-related complications. The literature is unclear on which technique is the safest.

AIM

To establish which approach has the lowest complication rate.

METHODS

A database search was performed from inception through November 2022, and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All included studies compared the two techniques directly and provided absolute values of the number of complications. Studies with pediatric populations were excluded. The primary outcome of this study was infection and bleeding. Pneumonia, peritonitis, pain, and mechanical complications were secondary outcomes. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB2) and we used The Risk of Bias in Nonrandomized Studies (ROBINS-I) to analyze the retrospective studies. We also performed GRADE analysis to assess the quality of evidence. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test.

RESULTS

Seventeen studies were included, including two randomized controlled trials and fifteen retrospective cohort studies. The total population was 465218 individuals, with 273493 having undergone PEG and 191725 PRG. The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG (95%CI: 0.03 to 0.08; P < 0.00001), although this outcome did not show significant difference in randomized studies (95%CI: -0.07 to 0.04; P = 0.13). There was no difference in the analyses of the following outcomes: infection in retrospective (95%CI: -0.01 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.04; P = 0.44) studies; bleeding in retrospective (95%CI: -0.00 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.02; P = 0.43) studies; pneumonia in retrospective (95%CI: -0.04 to 0.00; P = 0.28) or randomized (95%CI: -0.09 to 0.11; P = 0.39) studies; pain in retrospective (95%CI: -0.05 to 0.02; P < 0.00001) studies; peritonitis in retrospective (95%CI: -0.02 to 0.01; P < 0.0001) studies.

CONCLUSION

PEG has lower levels of tube-related complications (such as dislocation, leak, obstruction, or breakdown) when compared to PRG.

Homemade endoscopic vacuum therapy device for the management of transmural gastrointestinal defects

OBJECTIVES

Endoscopic vacuum therapy (EVT) possesses a unique mechanism of action providing a less invasive alternative for the management of transmural gastrointestinal defects (TGID). This study evaluates the efficacy and safety of a novel homemade EVT (H-EVT) for the treatment of TGID.

METHODS

Retrospective multicenter study including patients who underwent H-EVT for TGID between January 2019 and January 2022. Main outcomes included technical and clinical success as well as safety outcomes. Subgroup analyses were included by defect location and classification. Logistic regression analyses were performed to determine predictors for successful closure.

RESULTS

A total of 144 patients were included. Technical success was achieved in all patients, with clinical success achieved in 88.89% after a mean of 3.49 H-EVT exchanges over an average of 23.51 days. After excluding 10 cases wherein it was not possible to achieve negative pressure, successful closure occurred in 95.52% of patients. Time to clinical success was less for defects caused by endoscopic (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.33-1.20) compared to surgical procedures and for patients with simultaneous intracavitary and intraluminal H-EVT placement (HR 0.70; 95% CI 0.55-0.91). Location and classification of defect did not impact clinical success rate. Simultaneous placement of both an intraluminal and intracavitary H-EVT (odds ratio 3.08; 95% CI 1.19-7.95) was a significant predictor of clinical success. Three device-related adverse events (2.08%) occurred.

CONCLUSIONS

The use of the H-EVT is feasible, safe, and effective for the management of TGID.

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

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

Endoscopic ultrasound artificial intelligence-assisted for prediction of gastrointestinal stromal tumors diagnosis: A systematic review and meta-analysis

BACKGROUND

Subepithelial lesions (SELs) are gastrointestinal tumors with heterogeneous malignant potential. Endoscopic ultrasonography (EUS) is the leading method for evaluation, but without histopathological analysis, precise differentiation of SEL risk is limited. Artificial intelligence (AI) is a promising aid for the diagnosis of gastrointestinal lesions in the absence of histopathology.

AIM

To determine the diagnostic accuracy of AI-assisted EUS in diagnosing SELs, especially lesions originating from the muscularis propria layer.

METHODS

Electronic databases including PubMed, EMBASE, and Cochrane Library were searched. Patients of any sex and > 18 years, with SELs assessed by EUS AI-assisted, with previous histopathological diagnosis, and presented sufficient data values which were extracted to construct a 2 × 2 table. The reference standard was histopathology. The primary outcome was the accuracy of AI for gastrointestinal stromal tumor (GIST). Secondary outcomes were AI-assisted EUS diagnosis for GIST vs gastrointestinal leiomyoma (GIL), the diagnostic performance of experienced endoscopists for GIST, and GIST vs GIL. Pooled sensitivity, specificity, positive, and negative predictive values were calculated. The corresponding summary receiver operating characteristic curve and post-test probability were also analyzed.

RESULTS

Eight retrospective studies with a total of 2355 patients and 44154 images were included in this meta-analysis. The AI-assisted EUS for GIST diagnosis showed a sensitivity of 92% [95% confidence interval (CI): 0.89-0.95; P < 0.01), specificity of 80% (95%CI: 0.75-0.85; P < 0.01), and area under the curve (AUC) of 0.949. For diagnosis of GIST vs GIL by AI-assisted EUS, specificity was 90% (95%CI: 0.88-0.95; P = 0.02) and AUC of 0.966. The experienced endoscopists' values were sensitivity of 72% (95%CI: 0.67-0.76; P < 0.01), specificity of 70% (95%CI: 0.64-0.76; P < 0.01), and AUC of 0.777 for GIST. Evaluating GIST vs GIL, the experts achieved a sensitivity of 73% (95%CI: 0.65-0.80; P < 0.01) and an AUC of 0.819.

CONCLUSION

AI-assisted EUS has high diagnostic accuracy for fourth-layer SELs, especially for GIST, demonstrating superiority compared to experienced endoscopists' and improving their diagnostic performance in the absence of invasive procedures.

Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims

Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic.

Methods

A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results

Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I²=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I²=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I²=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I²=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events.

Conclusions

EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.

Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis

BACKGROUND

Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction (MDBO).

AIM

To compare the safety and efficacy of plastic stent (PS) vs self-expanding metal stent (SEMS) placement for treatment of MDBO.

METHODS

This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A comprehensive search was performed in MEDLINE, Cochrane, Embase, Latin American and Caribbean Health Sciences Literature, and grey literature to identify randomized clinical trials (RCTs) comparing clinical success, adverse events, stent dysfunction rate, reintervention rate, duration of stent patency, and mean survival. Risk difference (RD) and mean difference (MD) were calculated and heterogeneity was assessed with I² statistic. Subgroup analyses were performed by SEMS type.

RESULTS

Twelve RCTs were included in this study, totaling 1005 patients. There was no difference in clinical success (RD = -0.03, 95% confidence interval [CI]: -0.01, 0.07; I² = 0%), rate of adverse events (RD = -0.03, 95%CI: -0.10, 0.03; I² = 57%), and mean patient survival (MD = -0.63, 95%CI: -18.07, 19.33; I² = 54%) between SEMS vs PS placement. However, SEMS placement was associated with a lower rate of reintervention (RD = -0.34, 95%CI: -0.46, -0.22; I² = 57%) and longer duration of stent patency (MD = 125.77 d, 95%CI: 77.5, 174.01). Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS (RD = 152.25, 95%CI: 37.42, 267.07; I² = 98% and RD = 101.5, 95%CI: 38.91, 164.09; I² = 98%; respectively). Stent dysfunction was higher in the covered SEMS group (RD = -0.21, 95%CI: -0.32, -0.1; I² = 205%), with no difference in the uncovered SEMS group (RD = -0.08, 95%CI: -0.56, 0.39; I² = 87%).

CONCLUSION

While both stent types possessed a similar clinical success rate, complication rate, and patient-associated mean survival for treatment of MDBO, SEMS were associated with a longer duration of stent patency compared to PS.

Rare and Fatal Gastrointestinal Mucormycosis (Zygomycosis) in a COVID-19 Patient: A Case Report

The novel coronavirus disease (COVID-19) quickly spread to all continents. However, data regarding all the signs and symptoms of COVID-19 are insufficient. Patients with COVID-19 might present higher susceptibility to fungal coinfections. Mucormycosis is a rare and often life-threatening fungal disease characterized by vascular invasion by hyphae, resulting in thrombosis and necrosis. This is the first case report of mucormycosis in a COVID-19 patient. An 86-year-old male patient was admitted to the emergency room with acute diarrhea, cough, dyspnea, and fever from 5 days prior. Blood tests revealed a hemoglobin level of 14.3 mg/dL. Five days following the admission, the patient presented with melena and a hemoglobin level of 5.6 mg/dL. A transfusion of three units of red blood cells was required. Esophagogastroduodenoscopy revealed two giant gastric ulcers with necrotic debris and a deep hemorrhagic base without active bleeding. Furthermore, biopsies confirmed mucormycosis. Despite intensive care, the patient died 36 hours after the esophagogastroduodenoscopy.

Gastrointestinal Manifestations and Associated Health Outcomes of COVID-19: A Brazilian Experience From the Largest South American Public Hospital

OBJECTIVES

Brazil has rapidly developed the second-highest number of COVID-19 cases in the world. As such, proper symptom identification, including gastrointestinal manifestations, and relationship to health outcomes remains key. We aimed to assess the prevalence and impact of gastrointestinal symptoms associated with COVID-19 in a large quaternary referral center in South America.

METHODS

This was a single-center cohort study in a COVID-19 specific hospital in São Paulo, Brazil. Consecutive adult patients with laboratory confirmed SARS-CoV-2 were included. Baseline patient history, presenting symptoms, laboratory results, and clinically relevant outcomes were recorded. Regression analyses were performed to determine significant predictors of the gastrointestinal manifestations of COVID-19 and hospitalization outcomes.

RESULTS

Four-hundred patients with COVID-19 were included. Of these, 33.25% of patients reported ≥1 gastrointestinal symptom. Diarrhea was the most common gastrointestinal symptom (17.25%). Patients with gastrointestinal symptoms had higher rates of concomitant constitutional symptoms, notably fatigue and myalgia (p<0.05). Gastrointestinal symptoms were also more prevalent among patients on chronic immunosuppressants, ACE/ARB medications, and patient with chronic kidney disease (p<0.05). Laboratory results, length of hospitalization, ICU admission, ICU length of stay, need for mechanical ventilation, vasopressor support, and in-hospital mortality did not differ based upon gastrointestinal symptoms (p>0.05). Regression analyses showed older age [OR 1.04 (95% CI, 1.02-1.06)], male gender [OR 1.94 (95% CI, 1.12-3.36)], and immunosuppression [OR 2.60 (95% CI, 1.20-5.63)], were associated with increased mortality.

CONCLUSION

Based upon this Brazilian study, gastrointestinal manifestations of COVID-19 are common but do not appear to impact clinically relevant hospitalization outcomes including the need for ICU admission, mechanical ventilation, or mortality.