Safety and effectiveness of balloon cryoablation for treatment of Barrett's associated neoplasia: systematic review and meta-analysis.

Background and study aims Balloon cryoablation (BC) is a novel procedure for endoscopic ablation of Barrett's esophagus (BE- associated neoplasia. We performed a meta-analysis to assess the feasibility, effectiveness, and safety of BC for treatment of BE neoplasia. Patients and methods Several databases were searched for relevant articles (PubMed, Web of Science, Google Scholar, EMBASE) as well as abstracts of recent gastroenterology meetings. Data extraction was performed by two investigators using standardized forms, including age, gender, length of BE segment, prior treatments, procedural time and number ablation sessions, technical feasibility, adverse events, and eradication rates of intestinal metaplasia (CE-IM) and dysplasia (CE-D) at follow-up. Quality of the studies was assessed using a modified Newcastle Ottawa Scale. Results Seven studies met inclusion criteria for a total of 548 ablation sessions in 272 patients. The most common histopathology reported prior to BC was high-grade dysplasia (n = 131), followed by low-grade dysplasia (n = 75), and intramucosal adenocarcinoma (n = 52). The pooled rate for technical feasibility was 95.8 % (95 % CI: 93.6-97.5 %; I 2  = 13.2 %; P  = 0.3). Pooled rates of CE-IM and CE-D were 85.8 % (95 % CI: 77.8-92.2 %, I 2  = 55.5 %; p = 0.04) and 93.8 % (95 % CI: 85.5-98.7 %, I 2  = 74.2 %; P  = 0.001), respectively. The overall adverse event (AE) rate was 12.5 % (34 out of 272 patients), of which stricture formation was the most common (5.8 %), followed by mucosal laceration (0.7 %), perforation (0.4 %), and bleeding (0.4 %). All AEs were successfully managed endoscopically. Conclusion This meta-analysis suggests that BC is a safe and effective ablative technique for treatment of BE neoplasia; future prospective comparative trials are needed to corroborate these initial findings.

Discrepancy between self-reported and actual colonoscopy polypectomy practices for the removal of small polyps.

BACKGROUND AND AIMS: Cold snare polypectomy (CSP) is associated with higher rates of complete resection compared with cold biopsy forceps (CBF) for the removal of small polyps (4-9 mm). This study aimed to evaluate self-reported polypectomy preferences and actual practice patterns among endoscopists at an academic center and to identify factors associated with the use of CSP for small polyps. METHODS: In phase A, endoscopists completed a survey evaluating preferences for polypectomy techniques. In phase B, we performed a retrospective analysis of all consecutive colonoscopies with polypectomy (January 2016 to September 2018). Uni- and multivariate analysis were performed to identify factors associated with CSP for small polyps. RESULTS: Nineteen of 26 (73%) endoscopists completed the survey (phase A); 3 (15.8%) were interventional endoscopists. Most respondents indicated that they use CSP (89.5%) for small polyps and identified no reasons for choosing CBF over CSP (73.7%). In phase B, we identified 1118 colonoscopies with 2625 polypectomies for polyps ≤9 mm. Most diminutive polyps (≤3 mm) were removed with CBF (819 of 912; 90%). CBF (46.2%) was also preferentially used for removal of small polyps (n = 1713), followed by hot snare polypectomy (27.2%), and CSP (26.6%). On multivariate analysis, interventional endoscopists were associated with a higher likelihood of using CSP for small polyps (odds ratio, 1.38; 95% confidence interval, 1.07-1.79; P = .01). CONCLUSIONS: Significant discrepancy exists between self-reported preferences and actual polypectomy practices. CBF is still preferentially used over CSP for the removal of polyps sized 4-9 mm; further strategies are needed to monitor and implement adequate polypectomy techniques.

Embolic Stroke Diagnosed by Elevated D-Dimer in a Patient With Negative TEE for Cardioembolic Source.

We report a case of cerebrovascular accident with thromboembolic stroke etiology in a patient who had atrial flutter and negative transesophageal echocardiography (TEE) results. The increased D-dimer levels (1877 ng/mL) initiated referral for magnetic resonance imaging and magnetic resonance angiography of the brain that showed classic recanalization of an embolic thrombus in the angular branch of the left middle cerebral distribution. The D-dimer level of this patient was normalized after 3 months of anticoagulation therapy. Although TEE is considered the gold standard for evaluation of cardiac source of embolism, exclusion of intracardiac thrombus with TEE alone does not eliminate the risk of thromboembolic events. This case highlights the utility of D-dimer as a potential adjunct in the decision-making process to guide investigation of thromboembolism, determine subsequent therapy, and hence reduce the risk of embolic stroke recurrence.