Early versus late endoscopic treatment of pancreatic necrotic collections: A systematic review and meta-analysis.

Background and study aims Recently studies have compared early (<4 weeks) vs. late or standard (>4 weeks) endoscopic treatment of pancreatic necrotic collections (PNC) and have reported favorable results for early treatment. In this meta-analysis, we compared the efficacy and safety of early vs. late endoscopic treatment of PNC. Patients and methods We reviewed several databases from inception to September 30, 2021 to identify studies that compared early with late endoscopic treatment of PNC. Our outcomes of interest were adverse events (AEs), resolution of PNC, performance of direct endoscopic necrosectomy, need for further interventions, and mean number of endoscopic necrosectomy sessions. We calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs) for categorical variables and mean differences (MDs) with 95% CIs for continuous variables. Data were analyzed by random effect model. Heterogeneity was assessed by I 2 statistic. Results We included four studies with 427 patients. We found no significant difference in rates of AEs, RR (95% CI) 1.70 (range, 0.56-5.20), resolution of necrotic or fluid collections, RR (95% CI) 0.89 (range, 0.71-1.11), need for further interventions, RR (95% CI) 1.47 (range, 0.70-3.08), direct necrosectomy, RR (95% CI) 1.39 (range, 0.22-8.80), mortality, RR (95% CI) 2.37 (range, 0.26-21.72) and mean number of endoscopic necrosectomy sessions, MD (95% CI) 1.58 (range,-0.20-3.36) between groups. Conclusions Early endoscopic treatment of PNC can be considered for indications such as infected necrosis or sterile necrosis with symptoms or complications; however, future large multicenter studies are required to further evaluate its safety.

Efficacy and safety of EUS-guided gallbladder drainage for rescue treatment of malignant biliary obstruction: A systematic review and meta-analysis.

ERCP is the first line of treatment for malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. EUS-guided gallbladder drainage (EUS-GBD) has been suggested as a rescue treatment for patients who fail EUS-BD and ERCP. In this meta-analysis, we have evaluated the efficacy and safety of EUS-GBD as a rescue treatment of malignant biliary obstruction after failed ERCP and EUS-BD. We reviewed several databases from inception to August 27, 2021, to identify studies that evaluated the efficacy and/or safety of EUS-GBD as a rescue treatment in the management of malignant biliary obstruction after failed ERCP and EUS-BD. Our outcomes of interest were clinical success, adverse events, technical success, stent dysfunction requiring intervention, and difference in mean pre- and postprocedure bilirubin. We calculated pooled rates with 95% confidence intervals (CI) for categorical variables and standardized mean difference (SMD) with 95% CI for continuous variables. We analyzed data using a random-effects model. We included five studies with 104 patients. Pooled rates (95% CI) of clinical success and adverse events were 85% (76%, 91%) and 13% (7%, 21%). Pooled rate (95% CI) for stent dysfunction requiring intervention was 9% (4%, 21%). The postprocedure mean bilirubin was significantly lower compared to preprocedure bilirubin, SMD (95% CI): -1.12 (-1.62--0.61). EUS-GBD is a safe and effective option to achieve biliary drainage after unsuccessful ERCP and EUS-BD in patients with malignant biliary obstruction.

Cold snare versus cold forceps polypectomy for endoscopic resection of diminutive polyps: meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: The practices for resection of diminutive colon polyps vary among endoscopists, and U.S. Multi-Society Task force guidelines recommend use of cold snare polypectomy (CSP) for this purpose. In this meta-analysis, we compared CSP and cold forceps polypectomy (CFP) for resection of diminutive polyps. METHODS: Several databases were reviewed to identify randomized controlled trials that compared CSP and CFP for resection of diminutive polyps. The study outcomes of interest were complete resection of all diminutive polyps, complete resection of polyps ≤3 mm in size, failure of tissue retrieval, and polypectomy time. For categorical variables, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated; for continuous variables, mean differences (MDs) with 95% CIs were calculated. Data were analyzed by using a random-effects model, and heterogeneity was assessed by using the I2 statistic. RESULTS: We included 9 studies with 1037 patients. Rate of complete resection of all diminutive polyps was significantly higher in the CSP group (OR, 1.68; 95% CI, 1.09-2.58). Subgroup analysis, including jumbo or large-capacity forceps, found no significant difference in complete resection between groups (OR, 1.43; 95% CI, .80-2.56). We found no significant between-groups in the rates of complete resection of polyps ≤3 mm in size (OR, .83; 95% CI, .30-2.31). Rate of failure of tissue retrieval was significantly higher in the CSP group (OR, 10.13; 95% CI, 2.29-44.74). No significant between-group difference was noted in polypectomy time. CONCLUSIONS: CFP using large-capacity or jumbo biopsy forceps is noninferior to CSP for complete resection of diminutive polyps.

Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Over-The-Scope Clips (OTSC) use have shown promising results for first line treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). We conducted this meta-analysis to compare outcomes in patients treated with OTSC versus standard endoscopic intervention for first line endoscopic treatment of NVUGIB. METHODS: We reviewed several databases from inception to December 9, 2022 to identify studies comparing OTSC and standard treatments as the first line treatment for NVUGIB. The outcomes assessed included re-bleeding, initial hemostasis, need for vascular embolization, mortality, need for repeat endoscopy, 30 day readmission rate, and need for surgery. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using random effect model. Heterogeneity was assessed by I2 statistic. RESULTS: We included 11 studies with 1608 patients (494 patients in OTSC group and 1114 patients in control group). OTSC use was associated with significantly lower risk of re-bleeding (RR, 0.58; 95% CI 0.41-0.82). We found no significant difference in rates of initial hemostasis (RR, 1.05; 95% CI 0.99- 1.11), vascular embolization rates (RR, 0.93; 95% CI 0.40- 2.13), need for repeat endoscopy (RR, 0.78; 95% CI 0.40-1.49), 30 day readmission rate (RR, 0.59; 95% CI 0.17-2.01), need for surgery (RR, 0.81; 95% CI 0.29-2.28) and morality (RR, 0.69; 95% CI 0.38-1.23). CONCLUSIONS: OTSC are associated with significantly lower risk of re-bleeding compared to standard endoscopic treatments when used as first line endoscopic therapy for NVUGIB.

Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction - A systematic review and meta-analysis.

Background and Objectives: ERCP is the first line of treatment for benign and malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. Recently, several studies have evaluated the role of EUS-BD in the management of benign biliary obstruction. This meta-analysis evaluates the efficacy and safety of EUS-BD in the management of benign biliary obstruction. Methods: We reviewed several databases from inception to July 8, 2022, to identify studies evaluating the efficacy and safety of EUS-BD in the management of benign biliary obstruction. Our outcomes of interest were technical success, clinical success, and adverse events. Pooled rates with 95% confidence intervals (CIs) for all outcomes were calculated using a random effects model. Subgroup analyses were performed including patients with normal anatomy versus surgically altered anatomy (SAA). Heterogeneity was assessed by I2 statistic. Results: We included 14 studies with 329 patients. The pooled rate (95% CI) of technical success was 88% (83%, 92%). The pooled rate (95% CI) of technical success for patients with SAA and normal anatomy was 92% (85%, 96%) and 83% (75%, 89%), respectively. The pooled rates (95% CI) of clinical success and adverse events were 89% (83%, 93%) and 19% (13%, 26%), respectively. We found low heterogeneity in most of the analyses. Conclusions: EUS-BD is an effective and safe option in patients with benign biliary obstruction and should be considered after a failed attempt at ERCP or when ERCP is not technically possible.

The role and timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: A nationwide analysis.

BACKGROUND/PURPOSE: The role and optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis without cholangitis (ABPwoC) remains unclear. Using a large national database, we aimed to examine hospitalization outcomes of patients with ABPwoC as a function of the performance and timing of ERCP. METHODS: This was a retrospective study of adult patients with ABPwoC utilizing the National Inpatient Sample from 2016-2017. Patients who underwent inpatient ERCP were stratified into performance: within 24, 24-48, 48-72, and >72 h of hospital admission. The primary outcome was all-cause inpatient mortality as a function of the performance and timing of ERCP; secondary outcomes, including healthcare utilization, were assessed. Multivariate modeling was used to adjust for potential confounders. Statistical analyses were conducted using STATA, version 16.0. RESULTS: Of the 70 030 patients with ABPwoC, 31.37% underwent inpatient ERCP. Performance (aOR: 0.6, p < .05), but not timing (aOR: 0.98, p = .9), of inpatient ERCP was associated with significantly lower all-cause inpatient mortality. Urgent ERCP (within 24 h) was associated with shorter hospital length of stay, lower charges and cost, and less need for pancreatic drainage procedures, while ERCP within 72 h was associated with less frequent intensive care unit admission (all p < .05). DISCUSSION: Based on this large, nationwide analysis, inpatient ERCP for ABPwoC is associated with lower all-cause mortality. ERCP within 24 and 72 h, though not associated with lower mortality, are associated with multiple improved clinical outcomes, including lower healthcare charges and costs.

Predictors of Fecal Microbiota Transplant Failure in Clostridioides difficile Infection : An Updated Meta-analysis.

INTRODUCTION AND AIM: Fecal microbiota transplantation (FMT) is an effective treatment for recurrent/refractory Clostridioides difficile infection (CDI) with a 10% to 20% risk of recurrence after a single FMT. In this meta-analysis, we aimed to evaluate the predictors of FMT failure. METHODS: A comprehensive search of MEDLINE, Embase, Cochrane, and Web of Science databases through July 2021 was performed. All studies that evaluated risk factors associated with FMT failure in a multivariate model were included. We calculated pooled odds ratios with 95% confidence intervals for risk factors reported in ≥3 studies using a random-effects model. RESULTS: Twenty studies involving 4327 patients (63.6% females) with recurrent/refractory CDI who underwent FMT were included. FMT failed in 705 patients (16.3%) with 2 to 3 months of follow-up in most studies. A total of 12 different risk factors were reported in a multivariate model in ≥3 studies. Meta-analysis showed that advanced age, severe CDI, inflammatory bowel disease, peri-FMT use of non-CDI antibiotics, prior CDI-related hospitalizations, inpatient status, and poor quality of bowel preparation were significant predictors of FMT failure. Charlson Comorbidity Index, female gender, immunosuppressed status, patient-directed donor, and number of CDI recurrences were not associated with FMT failure. CONCLUSIONS: Adequate bowel preparation at the time of FMT and optimizing antibiotic stewardship practices in the peri-FMT period can improve the success of FMT. Patients with nonmodifiable risk factors should be counseled about the risk of FMT failure. Our results may help develop a risk stratification model to predict FMT failure in CDI patients.

Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis.

Background and study aims The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.

Fatal Venous Gas Embolism During Endoscopic Retrograde Cholangiopancreatography After Simultaneous Deployment of 2 Self-Expandable Metallic Stents.

Gas embolisms are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). While there have been multiple reports of ERCP-associated air embolisms, only 2 case reports using oral cholangioscopy and CO2 insufflation have been reported in the literature. We present a unique case of a fatal CO2 venous air embolism during ERCP without using cholangioscopy and with no intentional CO2 insufflation of the biliary tree.

Second exam of right colon improves adenoma detection rate: Systematic review and meta-analysis of randomized controlled trials.

Background and study aims A second examination of the right colon, either as a second forward view (SFV) or as retroflexion (RF) in the cecum, can increase adenoma detection rate (ADR) in the right colon. In this meta-analysis, we have evaluated the role of a second examination of the right colon in improving ADR. Methods We reviewed several databases to identify randomized controlled trials that compared right colon SFV with no SFV, and RCTs that compared SFV with RF in the right colon, and reported data on ADR. Our outcomes of interest were ADR and polyp detection rate (PDR) with SFV vs no SFV, right colon and total withdrawal times, and additional ADR and PDR with SFV vs RF. For categorical variables, we calculated pooled risk ratios (RRs) with 95 % confidence intervals (CIs); for continuous variables, we calculated standardized mean difference (SMD) with 95 % CI. Data were analyzed using random effects model. Results We included six studies with 3901 patients. Comparing SFV with no SFV, right colon ADR and PDR were significantly higher in the SFV group: ADR (RR [95 % CI] 1.39 [1.22,1.58]) and PDR (RR [95 % CI] 1.47 [1.30, 1.65]). We found no significant difference in right colon withdrawal time (SMD [95 % CI] 1.54 [-0.20,3.28]) or total withdrawal time (SMD (95 % CI) 0.37 [-0.39,1.13]) with and without SFV. We found no significant difference in additional ADR between SFV and RF. Conclusions SFV of the right colon significantly increases right-sided and overall ADR.

Metal versus plastic stents in the management of benign biliary strictures: systematic review and meta-analysis of randomized controlled trials.

Benign biliary strictures (BBS) are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with the placement of multiple plastic stents (MPS) or a covered self-expandable metal stent (CSEMS). In this meta-analysis, we compared the efficacy and safety of MPS and CSEMS in the management of BBS. We reviewed several databases from inception to 28 April 2021 to identify RCTs that compared MPS with CSEMS in the management of BBS. Our outcomes of interest were stricture resolution, stricture recurrence, adverse events, stent migration and mean number of ERCPs to achieve stricture resolution. Data were analyzed using a random-effects model. We included eight RCTs with 524 patients. We found no significant difference in the rate of stricture resolution (risk ratio, 1.02; 95% CI, 0.96-1.10), stricture recurrence (risk ratio, 1.68; 95% CI, 0.72-3.88) or adverse events (risk ratio, 1.17; 95% CI, 0.73-1.87) between groups. Mean number of ERCPs was significantly lower in the CSEMS group (SMD, -1.99; 95% CI, -3.35 to -0.64). The rate of stent migration was significantly higher in the CSEMS group. CSEMS are comparable in efficacy and safety to MPS in the management of BBS but require fewer ERCPs to achieve stricture resolution.

Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA.

BACKGROUND: Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. AIM: The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. METHODS: We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. RESULTS: A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. CONCLUSION: Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.

Early Colonoscopy Does Not Affect 30-Day Readmission After Lower GI Bleeding: Insights from a Nationwide Analysis.

INTRODUCTION: Lower gastrointestinal bleeding (LGIB) is one of the most common indications for hospital admission. The current standard of care for patients admitted with LGIB includes colonoscopy. The aims of this study are to define the rate of readmission in patients with LGIB and to determine whether early colonoscopy within the first 24 h after admission impacts the rate of readmission in these patients. METHODS: We performed a retrospective cohort study on data obtained from the Nationwide Readmission Database and identified patients admitted with lower GI bleed using ICD-10 codes. The primary outcome was 30-day all-cause readmission, and one of our secondary outcomes was the impact of early colonoscopy on 30-day readmission. RESULTS: We analyzed data from 35,790,513 patients who were admitted for LGIB in 2017. A total of 16.4% of these patients were readmitted within 30 days of discharge, with diverticular bleeding most common diagnosis for readmission. Overall, in-hospital mortality was 1.18% for index admission and 4.44% for readmission. Early colonoscopy did not impact the rate of readmission within 30 days of discharge. CONCLUSION: LGIB remains a commonly encountered in clinical practice with a high readmission rate. Mortality is significantly higher during readmission compared to index admission. Early colonoscopy did not impact the 30-day readmission rate.

Outcomes of Endoscopic Submucosal Dissection for Treatment of Superficial Pharyngeal Cancers: Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Studies evaluating the role of endoscopic submucosal dissection (ESD) in the management of superficial pharyngeal cancers have reported promising results. This meta-analysis evaluates the efficacy and safety of ESD in the management of superficial pharyngeal cancers. METHODS: We reviewed several databases from inception to September 03, 2020, to identify studies evaluating the efficacy and safety of ESD in the management of superficial pharyngeal cancers. Our outcomes of interest were en bloc resection rate, complete resection rate, adverse events, and rates of local recurrence. Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using random-effect model. Heterogeneity was assessed by I2 statistic. We assessed publication bias by using funnel plots and Egger's test. We conducted meta-regression analysis to explore heterogeneity in analyses. RESULTS: Ten studies were included in analyses. All studies were from Asia. Pooled rates (95% CI) for en bloc resection and complete resection were 94% (87%, 97%) and 72% (62%, 80%), respectively. The pooled rates (95% CI) for adverse events and local recurrence were 10% (5%, 17%) and 1.9% (0.9%, 4%), respectively. Most of the analyses were limited by substantial heterogeneity. On meta-regression analysis, the heterogeneity was explained by size of tumor and histology. Funnel plots and Egger's test showed no evidence of publication bias. CONCLUSIONS: This meta-analysis including studies from Asian countries demonstrated that ESD is an efficacious and safe option in the management of superficial pharyngeal cancers. More studies and studies from Western countries are needed to further validate these findings.

Impact of Readmission for Variceal Upper Gastrointestinal Bleeding: A Nationwide Analysis.

BACKGROUND: Variceal upper gastrointestinal bleeding (VUGIB) is a common and potentially lethal complication of cirrhosis. Population-based data regarding hospital readmission and other outcomes in VUGIB are limited. AIM: In a large United States database of patients with VUGIB, we evaluated readmission rates, mortality rates, healthcare resource consumption, and identified predictors of readmission. METHODS: The 2017 Nationwide Readmission Database using ICD-10 codes was used to identify all adult patients admitted for VUGIB. Primary outcomes were 30- and 90-day readmission rates. Secondary outcomes included mortality, healthcare resource consumption, and predictors of readmission. Multivariate regression analysis was used to adjust for potential confounders. RESULTS: In 2017, there were 26,498 patients with VUGIB discharged from their index hospitalization, and 24.7% were readmitted (all-cause) within 30-days and 41.5% within 90-days. Recurrent VUGIB accounted for 26.7% and 28.9% of 30- and 90-day readmissions, respectively. Compared to index admissions, 30-day readmissions were associated with higher mortality (4.3% vs. 6.4%, p < 0.01), increased mean hospital length of stay (5.6 days vs. 4.5 days, p < 0.01), and charges ($65,984 vs. $53,784, p < 0.01), with similar findings in 90-day readmissions. Factors associated with 30-day readmission included end-stage renal disease (HR 1.2, p < 0.05), chronic kidney disease (HR 1.31, p < 0.01), and acute kidney injury (HR 1.14, p < 0.05). CONCLUSION: Based on a nationwide cohort of hospitalized VUGIB patients, 25% were readmitted within 30-days and 42% within 90-days. Readmission was associated with increased mortality and healthcare consumption compared to the index admission. Additionally, acute and chronic renal injury were predictors of patients at high-risk for readmission.

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.

Systematic review with meta-analysis: one-year outcomes of gastric peroral endoscopic myotomy for refractory gastroparesis.

BACKGROUND: Several studies have examined the efficacy of gastric peroral endoscopic myotomy (G-POEM) for gastroparesis. AIM: To evaluate the mid-term efficacy of G-POEM by meta-analysis of studies with a minimum 1 year of follow-up. METHODS: We reviewed several databases from inception to 10 June 2021 to identify studies that evaluated the efficacy of G-POEM in refractory gastroparesis, and had at least 1 year of follow-up. Our outcomes of interest were clinical success at 1 year, adverse events, difference in mean pre- and 1 year post-procedure Gastroparesis Cardinal Symptom Index (GCSI) score, and difference in mean pre- and post-procedure EndoFLIP measurements. We analysed data using a random-effects model and assessed heterogeneity by I2 statistic. RESULTS: We included 10 studies comprising 482 patients. Pooled rates (95% CI) of clinical success at 1 year and adverse events were 61% (49%, 71%) and 8% (6%, 11%), respectively. Mean GCSI at 1 year post-procedure was significantly lower than pre-procedure; mean difference (MD) (95% CI) -1.4 (-1.9, -0.9). Mean post-procedure distensibility index was significantly higher than pre-procedure in the clinical success group at 40 and 50 mL volume distension; standardised mean difference (95% CI) 0.82 (0.07, 1.64) and 0.91 (0.32, 1.49), respectively. In the clinical failure group, there was no significant difference between mean pre- and post-procedure EndoFLIP measurements. CONCLUSIONS: G-POEM is associated with modest clinical success at 1 year. Additional studies with longer follow-up are required to evaluate its longer-term efficacy.

Characteristics and Outcome of Patients with COVID-19 Undergoing Invasive Mechanical Ventilation for Respiratory Failure in a Tertiary Level Hospital in Nepal.

BACKGROUND: Corona virus disease 2019 has become a global health issue. The goal of this study was to investigate the characteristics and outcomes of patients with corona virus disease 2019 undergoing invasive mechanical ventilation and identify factors associated with mortality. METHODS: Ninety four consecutive critically ill patients with confirmed corona virus disease 2019 undergoing invasive mechanical ventilation were included in this retrospective, single-center, observational study. The outcome variable was mortality of patients undergoing invasive mechanical ventilation and factors associated with it during intensive care unit stay. RESULTS: Seventy nine (84%) out of 94 patients with confirmed corona virus disease 2019 who underwent invasive mechanical ventilation didn't survive. Ninety four percent of patients who had Type 2 Diabetes Mellitus did not survive in comparison to 72 percent of patients who didn't have Type 2 Diabetes Mellitus. Similarly, 48 (94.1%) out of 51 patients with a positive C-reactive protein value didn't survive in comparison to 31 (72%) out of 43 patients with a negative C-reactive protein. CONCLUSIONS: The presence of Type 2 Diabetes Mellitus and a positive C-reactive protein value were strongly associated with mortality. Patients with a Sequential organ failure assessment score of more than eight at intensive care unit admission and peak D-dimer level of more than or equal to two during intensive care unit stay didn't show significant association with mortality. These findings need further exploration through larger prospective studies.

Short versus standard peroral endoscopic myotomy for esophageal achalasia: a systematic review and meta-analysis.

BACKGROUND: Peroral endoscopic myotomy (POEM) is increasingly used to treat esophageal achalasia, but is associated with a high rate of gastroesophageal reflux disease (GERD). The aim of our meta-analysis was to compare short and standard POEM in terms of clinical success and postoperative GERD. METHODS: We conducted a systematic review and meta-analysis of studies that compared POEM using short myotomy with standard myotomy. The primary outcome was clinical success. Secondary outcomes were postoperative GERD, perioperative complications, operation time, and length of hospital stay. A random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A P-value <0.05 was considered statistically significant. RESULTS: We included 5 studies involving 474 esophageal achalasia patients. Short and standard myotomies were similar in terms of clinical success (RR 1.02, 95%CI 0.97-1.09), perioperative complications (RR 0.68, 95%CI 0.26-1.75), and length of hospital stay (MD 0.25 days, 95%CI -0.14-0.63). Operation time was shorter for short myotomy (MD -15.01 mins, 95%CI -20.34 - -9.67). Although reflux symptoms were similar (RR 0.94, 95%CI 0.51-1.74), short myotomy had a lower risk of reflux esophagitis on endoscopy (RR 0.61, 95%CI 0.39-0.98), and pathologic acid exposure on pH monitoring (RR 0.58, 95%CI 0.36-0.94). CONCLUSIONS: POEM using a shorter myotomy is comparable with standard myotomy in terms of efficacy and safety in the short-term setting. A short myotomy requires a shorter operation time and might reduce the occurrence of postoperative GERD.