Endoscopic Ultrasound-Guided Gastroenterostomy for the Palliation of Gastric Outlet Obstruction (GOO): A Systematic Review and Meta-analysis of the Different Techniques.

INTRODUCTION: Gastric outlet obstruction (GOO) is usually associated with a poor prognosis and a significant decrease in a patient's quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMS) has emerged as a safe and effective palliation procedure for GOO in patients that are unfit for surgery. Without an exclusive gold-standard technique for EUS-GE, we aimed to compare the currently available ones in this systematic review and meta-analysis, the first on this subspecialty. METHODS: A comprehensive search from multiple electronic databases was performed. The search had a particular emphasis on the techniques used in performing EUS-GE. We identified all the studies in which EUS-GE was performed as palliation for GOO from its inception to the current date. The outcomes analyzed were the following: technical and clinical success, total and severe adverse events (AEs), procedure duration, and length of hospital stay (LOHS). RESULTS: Twenty studies involving 863 patients were the basis of this statistical analysis. Patients underwent the following techniques: direct gastroenterostomy (DGE) (n=718), balloon-assisted gastroenterostomy (BAGE) (n=27), and endoscopic ultrasound (EUS)-guided double-balloon-occluded gastrojejunostomy bypass (n=118). In comparison to balloon-assisted techniques, DGE had a lower rate of AEs, -0.121 (95% CI -0.191 to -0.051 p=0.001); and LOHS for the DGE group, -2.684 (95% CI -1.031 to -4.337 p=0.001). The other analyzed outcomes presented no statistically significant differences. On a sub-analysis, BAGE showed a lower rate of AEs than EUS-guided double-balloon-occluded gastrojejunostomy bypass, -0.196 (95% CI -0.061 to -0.331 p=0.004). CONCLUSIONS: EUS-GE is a safe and effective procedure for palliating GOO. When correctly administered, any of the analyzed techniques may be used to palliate GOO with similar technical and clinical outcomes. DGE had significantly lower rates of AEs and LOHS, which can be inferred as a safer procedure. These results should be interpreted cautiously due to the limited few studies that are available and accessible. Therefore, further well-designed, randomized clinical studies on the topic are warranted to compare the different techniques from more sources.

Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography (ERCP) Versus Endoscopic Ultrasound-Directed Transgastric ERCP in Patients With Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for skilled endoscopists that can be even more challenging in some situations, including patients' post-Roux-en-y Gastric Bypass (RYGB) surgery. There is still no consensus on whether laparoscopic-assisted ERCP (LA-ERCP) or endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) is the most appropriate, safe, and feasible approach in patients with this type of post-surgical anatomy. This systematic review and meta-analysis aimed to examine both approaches' feasibility, efficacy, and safety in this situation. We searched for electronic databases (MEDLINE, EMBASE, Lilacs, Google Scholar, and Central Cochrane) to identify studies comparing LA-ERCP versus EDGE. Outcomes measured included technical success, adverse events (AEs) and serious AEs, length of stay (LOS), and procedural time. Descriptive data related to the EDGE procedure was also extracted. The risk of bias and the quality of evidence of the enrolled studies were assessed. Five studies, totalizing 268 patients (176 LA-ERCP and 92 EDGE), were included. There was no statistical difference in technical success and AEs between groups; however, the LOS and procedural times were shorter for the EDGE group. High rates of fistula closure and no weight regain were observed in EDGE. Both methods are feasible and safe techniques to perform ERCP in patients with RYGB anatomy, with comparable technical success and adverse events rate. However, EDGE is associated with shorter LOS and procedural time.

Endoscopic Treatment of Weight Regain Following Roux-en-Y Gastric Bypass: a Systematic Review and Meta-analysis.

Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 11.1%, and 6.6 ± 5.0%, respectively. Subgroup analysis showed that all outcomes were significantly higher in the group with FT suturing combined with argon plasma coagulation (APC) (p < 0.0001). Meta-analysis included 15 FT studies and showed greater results. Three studies described superficial-thickness suturing with pooled AWL of 3.0 ± 3.8, 4.4 ± 0.07, and 3.7 ± 7.4 kg at 3, 6, and 12 months, respectively. Two articles described APC alone with mean AWL of 15.4 ± 2.0 and 15.4 ± 9.1 kg at 3 and 6 months, respectively. Full-thickness suturing is effective at treating weight regain after RYGB. Performing APC prior to suturing seems to result in greater weight loss. Head-to-head studies are needed to confirm our results. Few studies adequately assess effectiveness of other endoscopic techniques.

Obesity Treatment with Botulinum Toxin-A Is Not Effective: a Systematic Review and Meta-Analysis.

The effectiveness of gastric injections of botulinum toxin-A (BTA) as primary treatment for obesity is not well known since results in literature are discrepant. Hence, we aimed to systematically review and meta-analyze the available data to assess the real effect of BTA therapy. We searched MEDLINE, Embase, Cochrane, SCOPUS, EBSCO, LILACS, and BVS. We considered eligible only randomized controlled trials enrolling obese patients comparing BTA versus saline injections. Our initial search identified 8811 records. Six studies fulfilled eligibility criteria. After critical appraisal, two articles were excluded and we meta-analyzed the remainder. The mean difference for absolute weight loss and BMI reduction were 0.12 [CI 95%, - 1.14, 1.38] and - 0.06 [95% CI, - 0.92, 0.81], respectively. Therefore, we concluded that treatment of obesity with BTA is not effective.