Hemospray Versus Conventional Therapy for Non-variceal Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Hemospray (TC-325; Cook Medical, Winston-Salem, NC) has been used effectively in hemostasis in non-variceal upper gastrointestinal (GI) bleeding. Current guidelines suggest using Hemospray as a temporizing measure or adjunct technique. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of Hemospray as a modality for primary hemostasis. We searched MEDLINE, CENTRAL, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) databases from inception to August 1, 2022. Three independent reviewers performed a comprehensive review of all original articles describing the application of Hemospray as the primary method of hemostasis in non-variceal upper GI bleeding patients. Three reviewers independently reviewed and abstracted data and assessed study quality using the Cochrane risk of bias tool. Primary outcomes were (1) primary hemostasis rate, (2) rebleeding rate until hospital discharge or death, (3) need for surgery, and (4) overall mortality rate. Of the 211 studies identified, 146 underwent title and abstract review, and four were included in the systematic review. Pooled results from 303 patients showed that compared to standard of care, Hemospray has significantly higher odds of primary hemostasis (OR: 3.48, 95% CI: 1.09-11.18, p = 0.04). There was no statistically significant difference in terms of rebleeding rates (OR: 0.79, 95% CI: 0.24-2.55, p = 0.69), need for surgery (OR: 1.62, 95% CI: 0.35-7.41, p = 0.54), or overall mortality (OR: 1.08, 95% CI: 0.56-2.08, p = 0.83). This systematic review and meta-analysis prove that Hemospray is a better modality of primary hemostasis in non-variceal upper GI bleeding when used as a primary method. At the same time, there is no significant difference in complications, including rebleeding, need for surgical intervention, and all-cause mortality.

The prevalence and impact of psychiatric comorbidities on hospitalized inflammatory bowel disease patients in the United States: insights from the National Inpatient Sample from 2009-2018.

Background: Patients with inflammatory bowel disease (IBD) are at increased risk of anxiety and mood disorders. This study examines the temporal trends and clinical impact of anxiety and mood disorder diagnoses in hospitalized IBD patients in the United States during a 10-year period. Methods: Using the National Inpatient Sample from 2009-2018, all IBD-related discharges in adults were analyzed. Primary outcomes were the prevalence and temporal trends of mood disorder and anxiety diagnoses for IBD-related admissions. The impact of the psychiatric comorbidities on clinical outcomes was also evaluated. Results: A total of 1,718,736 IBD-related discharged were identified. A diagnosis of anxiety or a mood disorder was found to have a prevalence of 16.44% and 18.97%, respectively, amongst IBD-related admissions. The prevalence of anxiety disorders amongst hospitalized IBD patients increased significantly (from 12.13% to 20.26%), whereas the prevalence of mood disorders did not (17.46% and 18.9%). IBD admissions with psychiatric comorbidities had lower rates of IBD-related complications or mortality during hospitalization compared to IBD admissions without comorbid psychiatric diagnoses. This population, however, was more likely to experience certain comorbidities such as Clostridioides difficile, pneumonia, and venous thromboembolism, as well as a longer hospitalization. Conclusions: The prevalence of comorbid anxiety among hospitalized IBD patients in the United States matches or exceeds the prevalence of anxiety in the general hospitalized population. Given its association with more in-hospital complications and a longer hospital stay, it is important to further understand how psychological screening and mental health services can improve the management of hospitalized IBD patients.

Safety and Efficacy of Endoscopic Submucosal Dissection in the Management of Gastric Tube Cancers After Esophagectomy: A Systematic Review.

Esophagectomy is the proposed standard of care for resectable primary esophageal cancers and recurrent lesions in the reconstructed gastric tube (GT); however, it carries significant morbidity and mortality. Endoscopic submucosal dissection (ESD) has established its role in the management of primary esophageal cancers with growing evidence of its safety in resecting recurrent primary lesions in GT. Our study aims to evaluate the safety and efficacy of ESD in the management of recurrent, localized primary esophageal cancers in GT. We searched PubMed, CENTRAL, EMBASE, Scopus, and clinical trial registries from inception to March 2023 for articles evaluating the safety and efficacy of ESD in the management of recurrent cancerous lesions in GT. Our primary outcome was the en bloc resection rate. Secondary outcomes were curative resection rate, complete resection rate, intra-procedural complication rate, post-procedure complication rate, and five-year survival rate. Seven studies with a total of 165 patients undergoing 192 ESDs were included in the review. The pooled en bloc resection rate was 92.5% (95% CI: 87.7-95.6), which was reported in all seven studies. Pooled complete resection rate was 78.9% (95% CI: 64.5-88.5) per three studies, pooled curative resection rate was 73.9% (95% CI: 63.5-82.2) per four studies, and pooled intra-procedural complication rate was 10.2% (95% CI: 1.5-46.3), which was reported in four studies. Only three studies reported a five-year survival rate that was 65.5% (95% CI: 56.0-73.9). ESD is safe and efficacious in the management of GT cancer after esophagectomy.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Background: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. Methods: A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. Results: A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Conclusion: Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Temporal trends and risk factors of gastrointestinal bleeding in patients with left ventricular assist devices: a nationwide analysis 2008-2017.

Background: Left ventricular assist devices (LVADs) are indicated for patients with end-stage heart failure and require systemic anticoagulation. Gastrointestinal (GI) bleeding is a major adverse event following LVAD implantation. There is paucity of data on healthcare resource utilization in patients with LVAD and the risk factors of associated bleeding, despite the increase in GI bleeding. We investigated the in-hospital outcomes of GI bleeding in patients with continuous-flow (CF) LVAD. Methods: This was a serial cross-sectional study of the Nationwide Inpatient Sample (NIS) in the CF-LVAD era from 2008-2017. All adults admitted to hospital with a primary diagnosis of GI bleeding were included. GI bleeding was diagnosed by ICD-9/ICD-10 codes. Patients with CF-LVAD (cases) and without CF-LVAD (controls) were compared using univariate and multivariate analyses. Results: A total of 3,107,471 patients were discharged with a primary diagnosis of GI bleeding during the study period. Of these, 6569 (0.21%) had CF-LVAD-related GI bleeding. Overall, bleeding angiodysplasia accounted for the majority (69%) of LVAD-related GI bleeding. There was no statistical difference in mortality, but the length of hospital stay increased by 2.53 days (95% confidence interval [CI] 1.78-2.98; P<0.001) and the mean hospital charge per stay increased by $25,980 (95%CI 21,267-29,874; P<0.001) in 2017 compared to 2008. The results were consistent after propensity score matching. Conclusion: Our study highlights that patients with LVAD admitted to the hospital for GI bleeding experience longer hospital stays and greater healthcare costs that warrant risk-based patient evaluation and careful implementation of management strategies.

Effectiveness and safety of SARS-CoV-2 vaccine in Inflammatory Bowel Disease patients: a systematic review, meta-analysis and meta-regression.

INTRODUCTION: There are concerns regarding the effectiveness and safety of SARS-CoV-2 vaccine in inflammatory Bowel Disease (IBD) patients. This systematic review and meta-analysis comprehensively summarises the available literature regarding the safety and effectiveness of SARS-CoV-2 vaccine in IBD. METHODS: Three independent reviewers performed a comprehensive review of all original articles describing the response of SARS-CoV-2 vaccines in patients with IBD. Primary outcomes were (1) pooled seroconversion rate SARS-CoV-2 vaccination in IBD patients (2) comparison of breakthrough COVID-19 infection rate SARS-CoV-2 vaccination in IBD patients with control cohort and (3) pooled adverse event rate of SARS-CoV-2 vaccine. All outcomes were evaluated for one and two doses of SARS-CoV-2 vaccine. Meta-regression was performed. Probability of publication bias was assessed using funnel plots and with Egger's test. RESULTS: Twenty-one studies yielded a pooled seroconversion rate of 73.7% and 96.8% in IBD patients after one and two doses of SARS-CoV-2 vaccine respectively. Sub-group analysis revealed non-statistically significant differences between different immunosuppressive regimens for seroconversion. Meta-regression revealed that the vaccine type and study location independently influenced seroconversion rates. There was no statistically significant difference in breakthrough infection in IBD patients as compared to control after vaccination. CONCLUSION: In summary, the systematic review and meta-analysis suggest that SARS-CoV-2 vaccine is safe and effective in IBD patients.

Evaluation of a U.S. National Cohort to Determine Utilization in Colectomy Rates for Ulcerative Colitis Among Ethnicities.

BACKGROUND: Colectomy is the curative management for ulcerative colitis (UC). Multiple studies have reported racial disparities for colectomy before the advent of anti-TNF alpha agents. The aim of this study was to describe racial and geographic differences in colectomy rates among hospitalized patients with UC after anti-TNF therapy was introduced. METHODS: We examined all patients discharged from the hospital between 2010 and 2014 with a primary diagnosis of UC or of complications of UC. The data were evaluated for race and colectomy rates among the hospitalized patients with UC. RESULTS: The unadjusted national colectomy rate among hospitalized patients with UC between 2010 and 2014 was 3.90 per 1000 hospitalization days (95% confidence interval, 3.72-4.08). The undajusted colectomy rates in African American (2.33 vs 4.35; P < 0.001) and Hispanic patients (3.99 vs 4.35; P ≤ 0.009) were considerably lower than those for White patients. After adjustment for confounders, the incidence rate ratio for African American as compared to White patients was 0.43 (95% confidence interval, 0.32-0.58; P < 0.001). Geographic region of the United States also showed significant variation in colectomy rates, with western regions having the highest rate (4.76 vs 3.20; P < 0.001). CONCLUSIONS: Racial and geographical disparities persist for the rate of colectomy among hospitalized patients with UC. The national database analysis reveals that colectomy rates for hospitalized African American and Hispanic patients were lower than those for White patients. Further studies are important to determine the social and biologic foundations of these disparities.

The Cook Score: A Novel Assessment for the Prediction of Liver-Associated Clinical Events in a Diverse Population.

BACKGROUND AND AIMS: Transient elastography (TE) provides accurate quantification of liver fibrosis. Its usefulness could be significantly amplified in terms of predicting liver-associated clinical events (LACE). Our aim was to create a model that accurately predicts LACE by combining the information provided by TE with other variables in patients with chronic liver disease (CLD). METHODS: We retrospectively reviewed the electronic medical records of patients who underwent liver elastography, at John H. Stroger Hospital in Cook County, Chicago, IL. The incidences of LACE were documented including decompensation of CLD, new hepatocellular carcinoma, and liver-associated mortality. Significant predicting factors were identified through a forward stepwise Cox regression model. We used the beta-coefficients of these risk factors to construct the Cook Score for prediction of LACE. Receiver-operating characteristic (ROC) curves were plotted for Cook Score to evaluate its efficiency in prediction, in comparison with MELD-Na Score and FIB-4 Score. RESULTS: A total of 3097 patients underwent liver elastography at our institution. Eighty-eight LACE were identified. Age (hazard ratio (HR) 1.04, p = 0.002), aspartate aminotransferase to alanine aminotransferase ratio (HR 2.61, p < 0.001), platelet count (HR 0.98, p < 0.001), international normalized ration (INR) (HR 17.80, p < 0.001), and liver stiffness measurement (HR1.04, p < 0.001) were identified as significant predictors. The Cook Score was constructed with two optimal cut-off points to stratify patients into low-, intermediate-, and high-risk groups for LACE. The Cook Score proved superior than MELD-Na Score and FIB4 Score in predicting LACE with an area under curve of 0.828. CONCLUSION: This novel score based on a large robust sample would provide accurate prediction of prognosis in patients with chronic liver disease and guide individualized surveillance strategy once validated with future studies.

Safety and Efficacy of Thrombin for Bleeding Gastric Varices: A Systematic Review and Meta-Analysis.

INTRODUCTION: The optimal therapy for bleeding-related gastric varices is still a controversial topic. There is a paucity of literature that comprehensively summarizes the available literature regarding safety and efficacy of thrombin in bleeding gastric varices. METHODS: Four independent reviewers performed a comprehensive review of all original articles published from inception to October 2020, describing the use of thrombin for management of bleeding gastric varices. Primary outcomes were (1) pooled early and late rebleeding rate, (2) pooled gastric variceal related mortality rate, (3) pooled rescue therapy rate, and (4) pooled adverse event rate with the use of thrombin in bleeding gastric varices. The meta-analysis was performed and the statistics were two-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test. RESULTS: Eleven studies were included in the analysis after comprehensive search. This yielded a pooled early rebleeding rate of 9.3% (95% CI 4.9-17) and late rebleeding rate 13.8% (95% CI 9-20.4). Pooled rescue therapy rate after injecting thrombin in bleeding gastric varices was 10.1% (95% CI 6.1-16.3). The pooled 6-week gastric variceal-related mortality rate after injecting thrombin in bleeding gastric varices was 7.6% (95% CI 4.5-12.5). There were a total of four adverse events out of a total of 222 patients with pooled adverse event rate after injecting thrombin in bleeding gastric varices was 5.6% (95% CI 2.9-10.6). CONCLUSION: In summary, the systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest low rates of rebleeding and minimal rates of adverse events. While, early and late rebleeding rate and rescue therapy rate are similar to cyanoacrylate-based therapy, the minimal rates of adverse events are perhaps the most important benefit of thrombin. Thus, the current data suggest that thrombin is a very promising therapeutic alternative with low risk of adverse events for bleeding gastric varices.

No Significant Difference in Post-ERCP Bleeding Rates Between Dual Antiplatelet Agents and Aspirin Alone: A Systematic Review and Meta-analysis.

BACKGROUND: Several professional society guidelines suggest holding antiplatelet agents before high-risk procedures. However, there is lack of high-grade evidence to support the recommendation as most of the studies have been single center with small sample sizes. We aimed to perform the first systematic review and meta-analysis comparing dual antiplatelet therapy (DAPT) versus aspirin alone in terms of postendoscopic retrograde cholangiopancreatography (ERCP) bleeding. METHODS: Three independent reviewers performed a comprehensive review of all original articles published from inception to May 2020, evaluating the post-ERCP bleeding rate in setting of DAPT. Primary outcomes were the overall post-ERCP bleeding rate with the use of dual antiplatelet therapy; comparison of post-ERCP bleeding rate in patients with DAPT versus aspirin alone. Secondary outcomes were comparison of immediate and delayed post-ERCP bleeding outcomes in the 2 cohorts. RESULTS: Six studies were included after a thorough search was concluded using the key words. The pooled analysis of studies revealed an overall post-ERCP bleeding rate of 5.7% (95% confidence interval: 3-10.6) on sustained DAPT. Post-ERCP bleeding in DAPT Cohort was not significantly higher as compared with aspirin only Cohort (odds ratio: 1.14, 95% confidence interval: 0.46-2.81). The immediate bleeding and delayed bleeding rates cannot be generalized due to low number of studies. CONCLUSIONS: The first systematic review and meta-analysis showed that post-ERCP bleeding rates are not significantly higher in DAPT cohort as compared with aspirin alone. Therefore, the risk of bleeding is less likely related to the antiplatelet agents and more likely related to the procedure itself.

Outcomes of Non-Variceal Upper Gastrointestinal Bleed Stratified by Hospital Teaching Status: Insights From the National Inpatient Sample.

BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a significant cause of mortality and morbidity in the USA. Currently, there are limited data on the inpatient outcomes of patients admitted with a diagnosis of NVUGIB stratified according to teaching hospital status. We analyzed data from the National Inpatient Sample (NIS) intending to evaluate these outcomes. METHODS: We queried the NIS 2016 and 2017 databases for NVUGIB hospitalizations by teaching hospital status. The primary outcome was inpatient mortality while secondary outcomes were rate of endoscopy for hemostasis, rate of early endoscopy (endoscopy in 1 day or less), mean time to endoscopy, rate of complications including acute kidney injury (AKI), acute respiratory failure (ARF), need for blood transfusion, development of sepsis, need for endotracheal intubation and mechanical ventilation as well as healthcare utilization. RESULTS: There were over 71 million weighted discharges in the combined 2016 and 2017 NIS database. A total of 94,900 NVUGIB cases were identified with 63.4% admitted in teaching hospitals. The in-hospital mortality for patients admitted with an NVUGIB in teaching hospitals was 1.98% compared to 1.5% in non-teaching hospitals (adjusted odds ratio (aOR): 1.38, 95% confidence interval (CI): 1.08 - 1.77, P = 0.010) when adjusted for biodemographic and hospital characteristics as well as comorbidities. Patients admitted with a diagnosis of NVUGIB in teaching hospitals had a 10% adjusted increased odds of getting endoscopy for hemostasis (27.0% vs. 24.5%, aOR: 1.10, 95% CI: 1.02 - 1.19, P = 0.016) compared to patients in non-teaching hospitals. There was, however, no difference in early endoscopy between the two groups. CONCLUSION: Patients admitted at teaching hospitals for an NVUGIB had worse outcomes during hospitalizations including mortality, median length of stay, and total hospital charges when compared to NVUGIB patients managed at non-teaching hospitals.

A comparison of 9-min colonoscopy withdrawal time and 6-min colonoscopy withdrawal time: A systematic review and meta-analysis.

INTRODUCTION: The optimal colonoscopy withdrawal time is still a controversial topic. While several studies demonstrate that longer withdrawal time improves adenoma detection rate, others have contradicted these findings. METHODS: Three independent reviewers performed a comprehensive review of all original articles published from inception to January 2021 and included studies reporting comparison of the two cohorts-(i) ≥ 6 but less than 9 min of colonoscopy withdrawal time (CWT) and (ii) ≥ 9 min of CWT. The outcome measures were the following: (i) adenoma detection rate (ADR), (ii) advanced ADR, and (iii) sessile serrated adenoma detection rate (SDR). The meta-analysis was performed, and the statistics were two-tailed. RESULTS: A total of seven studies met the inclusion criteria after a thorough search of the literature was completed. The analysis revealed that ≥ 9 min of CWT had significantly higher odds of adenoma detection as compared with 6-9 min of CWT (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.30-1.82; I2  = 93.7). Additionally, a significantly higher odds of sessile serrated adenoma detection (OR 1.68, 95% CI 1.28-2.22; I2  = 0) and a trend towards higher odds of advanced adenoma detection (OR 1.38, 95% CI 0.98-1.95, I2  = 90) were seen with CWT of at least 9 min when compared with 6-9 min of CWT. CONCLUSION: This systematic review and meta-analysis analysis provides further evidence that at least 9 min of CWT cohort had significantly higher ADR and SDR as compared with the at least 6 min but less than 9 min of cohort.

Acute pancreatitis in patients with COVID-19 is more severe and lethal: a systematic review and meta-analysis.

BACKGROUND: Emerging evidence suggests an association between acute pancreatitis and COVID-19. Our objective is to conduct a systematic review and meta-analysis to evaluate whether COVID-19 affects the severity and outcomes associated with acute pancreatitis. METHODS: Cochrane guidelines and PRISMA statement were followed for this review. Digital dissertation bases were searched and all studies comparing the outcomes of acute pancreatitis amongst patients with and without COVID-19 were included. We compared the etiology, severity, length of hospital stay and mortality associated with acute pancreatitis in patients with and without COVID-19. RESULTS: Four observational studies with a total of 2,419 patients were included in the review. Presence of COVID-19 significantly increased the odds of mortality (OR 4.10, 95% CI 2.03-8.29) in patients with acute pancreatitis. These patients also had an increased incidence of severe pancreatitis (OR 3.51, 95% CI 1.19-10.32), necrotizing pancreatitis (OR 1.84, 95% CI 1.19-2.85) and a longer length of hospital stay (OR 2.88, 95% CI 1.50-5.52), compared to non-COVID patients. Patients with COVID-19 were more likely to have an unknown or idiopathic etiology of acute pancreatitis (OR 4.02, 95% CI 1.32-12.29), compared to non-COVID-19 patients. CONCLUSION: Current evidence suggests that COVID-19 adversely impacts the morbidity and mortality associated with acute pancreatitis. SARS-CoV-2 may be a causative agent for acute pancreatitis. Further population-based studies are needed to confirm or refute these findings.

Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study.

BACKGROUND: The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort. METHODS: The cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the 2 cohorts. RESULTS: Overall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis. CONCLUSIONS: The increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician's suspicion about the severity of disease.

Efficacy and safety of primary needle-knife fistulotomy in biliary cannulation: a systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis on the efficacy and safety of primary needle-knife fistulotomy (NFK) in biliary cannulation. An electronic bibliographic search of digital dissertation databases was performed from inception till March 2020. All prospective studies, including randomized trials evaluating the use of NFK as a primary cannulation technique in biliary cannulation, were analyzed. The primary outcome was a successful cannulation rate and the secondary outcomes were post-ERCP pancreatitis rate and overall post-ERCP complication rate. A total of four prospective studies, including three randomized trials, were included for the analysis. The pooled cannulation success rate for primary NFK was 95.7% (95% CI. 83.1-99.0, P < 0.001). When compared with standard wire-guided cannulation, the analysis did not show any difference between the two techniques in terms of cannulation success (OR, 3.59, 95% CI, 0.34-37.39; P = 0.28; low certainty of evidence). The overall rate of post-ERCP pancreatitis with primary NFK was 1.5 % (95% CI, 0.6-3.9, P < 0.001). When compared with conventional wire-guided technique, the odds of developing post-ERCP pancreatitis with NFK were 0.22 (95% CI, 0.04-1.04, P = 0.06; moderate certainty of evidence). To conclude, NKF seems to be an effective means of biliary cannulation in expert hands. Although it may be associated with a lower rate of post-ERCP pancreatitis, the current strength and quality of evidence to support its use as a primary cannulation strategy is low. It may be considered in ERCPs at higher risk of pancreatitis by experienced endoscopists.

Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis.

ABSTRACT: Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.

Comparative Effectiveness of Fecal Immunochemical Tests versus Flexible Sigmoidoscopy for Colorectal Cancer Screening: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND AND AIMS: Fecal immunochemical tests (FITs) and flexible sigmoidoscopies are commonly used modalities for colorectal cancer (CRC) screening. We performed a systematic review and meta-analysis to compare the effectiveness of FIT and sigmoidoscopy in CRC screening. METHODS: PRISMA statement and Cochrane guidelines were followed for this review. Digital dissertation databases were searched from inception till December 1st 2020 and randomized clinical trials comparing the detection rates of CRC for FIT and sigmoidoscopy were included. Outcomes for analysis included participation rates and detection rates of CRC, advanced adenomas and advanced colorectal neoplasia for both screening modalities. RESULTS: Five randomized clinical trials with a total of 261,755 patients were included for the analysis. The participation rate for FIT was significantly higher compared to flexible sigmoidoscopy (OR 2.11, 95% CI 1.29-3.44, p=0.003). In intention-to-screen analysis, the detection rate for advanced colorectal neoplasia was significantly lower with FIT (OR 0.62, 95% CI 0.45-0.84, p=0.002) as compared to flexible sigmoidoscopy but not statistically different for CRC (OR 1.15, 95% CI 0.65-2.02, p=0.63). CONCLUSION: Despite lower participation amongst patients, CRC screening with flexible sigmoidoscopy leads to higher detection of advanced colorectal neoplasia, when compared to a single round of fecal immunochemical testing.

Incidence and risk factors for 30-day readmission in ulcerative colitis: nationwide analysis in biologic era.

BACKGROUND AND STUDY AIM: Ulcerative colitis (UC) is a chronic relapsing and remitting disease requiring frequent hospitalization. Biologics have become the recommended initial therapy for Biologics in patients with moderate to severe UC. Our aim was to estimate the changes in Nationwide Healthcare utilization and assess predictive factors of 30-day readmission, morbidity and mortality of UC. METHODS: This is a retrospective observational study analyzing the Nationwide Readmission database from 2016 to 2017 using ICD-10 codes. The primary outcomes of the study were to assess the predictors of 30-day readmission in patients with UC. RESULTS: Of the 54 138 adult patients with a primary diagnosis of UC, 13.2% were readmitted within 30 days of index hospitalization. The mortality rate (1.4 vs. 0.3%, P < 0.01), length of stay (7 vs. 4.9 days, P < 0.01) and hospital cost ($62 552 vs. $46 971, P < 0.01) were higher on readmission as compared to index hospitalization. We identified multiple patient-related factors (age <65years, men, VTE, protein calorie malnutrition, electrolyte imbalance, anemia, anxiety and alcohol abuse), hospital-related factors (teaching hospitals, high quintile hospitals), as independent predictors of 30-day UC readmission. Colonoscopy, Cannabis use, and colectomy were associated with decreased odds of 30-day readmission. The most common cause of UC was septicemia. CONCLUSIONS: This is the largest nationwide study demonstrating predictors of 30-day readmission, mortality and morbidity associated with UC. Identification and amelioration of these risk factors will decrease readmission rate and mortality amongst UC patients.

EUS guided pancreatic duct decompression in surgically altered anatomy or failed ERCP - A systematic review, meta-analysis and meta-regression.

INTRODUCTION: EUS-PD (EUS guided pancreatic duct drainage) is classified into two types: EUS-guided rendezvous techniques and EUS-guided PD stenting. Prior studies showed significant variation in terms of technical success, clinical success and adverse events. METHODS: Three independent reviewers performed a comprehensive review of all original articles published from inception to June 2020, describing pancreatic duct drainage utilizing EUS. Primary outcomes were technical success, clinical success of EUS-PDD and safety of EUS-PD in terms of adverse events. All meta-analysis and meta-regression tests were 2-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test. RESULTS: A total of sixteen studies (503 patients) described the use of EUS-PD for pancreatic duct decompression yielded a pooled technical success rate was 81.4% (95% CI 72-88.1, I 2 = 74). Meta-regression revealed that proportion of altered anatomy and method of dilation of tract explain the variance. Overall pooled clinical success rate was 84.6% (95% CI 75.4-90.8, I 2 = 50.18). Meta-regression analysis revealed that the type of pancreatic duct decompression, proportion of altered anatomy and follow up time explained the variance. Overall pooled adverse event rate was 21.3% (95% CI 16.8-26.7, I 2 = 36.6). The most common post procedure adverse event was post procedure pain. Overall pooled adverse event rate of post EUS-PD pancreatitis was 5% (95% CI 3.2-7.8, I 2 = 0). CONCLUSION: The systematic review, meta-analysis and meta-regression provides answer to the questions of the overall technical success, clinical success and the adverse event rate of EUS-PD by summarizing the available literature.