Endoscopic biliary treatment of unresectable cholangiocarcinoma: A meta-analysis of survival outcomes and systematic review.

BACKGROUND: Endoscopic radiofrequency ablation (ERFA), percutaneous radiofrequency ablation (PRFA), and photodynamic therapy (PDT), when used in conjunction with conventional biliary stenting, have demonstrated a survival benefit in patients with unresectable cholangiocarcinoma. AIM: To compare pooled survival outcomes, adverse event rates, and mean stent patency for those undergoing these procedures. METHODS: A comprehensive literature review of published studies and abstracts from January 2011 to December 2020 was performed comparing survival outcomes in patients undergoing ERFA with stenting, biliary stenting alone, PRFA with stenting, and PDT with stenting for unresectable cholangiocarcinoma (CCA). RESULTS: Data from four studies demonstrated a pooled mean survival favoring ERFA as compared to biliary stenting alone (12.0 ± 0.9 mo vs 6.8 ± 0.3 mo, P < 0.001) as well as statistically improved median survival time (13 mo vs 8 mo, P < 0.001). Both ERFA with stenting and PRFA with stenting groups demonstrated statistical superiority to biliary stenting alone (P < 0.001 and P = 0.004, respectively). However, when comparing ERFA to PRFA, pooled data demonstrated overall higher mean survival in the ERFA with stenting cohort as compared to PRFA with stent cohort (12.0 + 0.9 mo vs 8.1 + 2.1 mo, P < 0.0001). Data from two studies demonstrated a pooled median survival favoring ERFA with stenting as compared to PDT with stenting (11.3 mo vs 8.5 mo, P = 0.02). CONCLUSION: While further prospective, randomized studies are needed to assess efficacy of ERFA, our meta-analysis demonstrated that this technique offers endoscopists a reasonable palliative method by which to treat patients with unresectable CCA that results in longer survival as compared to biliary stenting alone, percutaneous radiofrequency ablation with biliary stenting, and PDT with biliary stenting as well as an acceptable adverse event profile based on available published data.

Do Gastroenterologists Have a "Weak" Day? Impact of Day of the Week on the Quality of Outpatient Screening Colonoscopies.

GOAL: The goal of this study is to determine the significance of day of the work week and its contribution to endoscopist performance using adenoma detection rate (ADR) and proposed surrogate quality measures. BACKGROUND: Nearly a quarter of adenomas are missed on routine screening colonoscopy which contributes to between 50% and 60% of interval colorectal cancer. MATERIALS AND METHODS: Adult patients who underwent outpatient screening colonoscopy between January 2015 and April 2020 were included. Measurement of ADR and proposed quality metrics were analyzed for each day of the work week. Secondary outcomes included rates of good or excellent bowel preparation, trainee fellow participation, performance quartile of individual endoscopists, and patient demographic data. A generalized linear mixed model was used to analyze predictors of ADR. RESULTS: A total of 1884 screening procedures were included in our analysis. ADR on Friday (35.6%) was significantly lower than all other days of the work week ( P <0.001). When compared with Friday, all days were found to be independent predictors of increased ADR. Male gender [95% confidence interval (CI): 1.12-1.65, P =0.002], good rather than excellent bowel preparation (95% CI: 1.22-2.28, P =0.001) and colonoscopy withdrawal time (CWT) (95% CI: 1.02-1.03, P <0.001) were all found to be predictors of increased ADR. Proposed quality indicators were all well correlated with ADR ( r >0.811, P ≤0.001) apart from CWT ( r =0.28, P =0.379). CONCLUSIONS: The data suggests there is a decline in endoscopist performance on Friday when compared with all other days of the work week. ADR correlates well with many proposed quality parameters, however, CWT may be of additional value as a quality metric.

Effect of the Weekend on Bowel Preparation Quality in Outpatient Colonoscopies.

INTRODUCTION: Inadequate bowel preparation has been associated with a higher likelihood of missing adenomatous polyps. Colonoscopies immediately following a weekend may be prone to inadequate bowel preparation. This study aims to evaluate if day of the week is a predictor of bowel preparation adequacy, while assessing other patient and procedural variables and their effect on the Boston Bowel Preparation Scale (BBPS). METHODS: A retrospective review was conducted of all adult patients undergoing outpatient colonoscopy between January 2015 and April 2020. Adequacy of bowel preparation was compared among all days of the week and days following federal holidays. Secondary outcomes included patient demographics, indication and timing of the procedure. RESULTS: Of 4,279 colonoscopies, Monday had the highest rate of inadequate preparation (BBPS < 6) (16.5%) compared to other days of the week (p < .001). Post-holiday procedures were not associated with poor bowel preparation (p = .901). Similarly, on multivariate analysis, we found that procedures on Monday (OR 1.67 95%CI 1.33-2.10, p < .001) and African-American race (OR 1.34 95%CI 1.11-1.62, p = .003) were associated with inadequate bowel preparation. Females were more likely to have adequate bowel preparation (OR 0.71 95%CI 0.59-0.86, p < .001). DISCUSSION: Bowel preparation on Mondays is more likely to be inadequate than other days of the week. Additionally, gender and ethnicity appear to be associated with quality of bowel preparation. A better characterization of procedural and patient variables can lead to a more personalized approach to bowel preparation.

Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study.

Background Walled-off pancreatic necrosis (WOPN) represents an encapsulated collection of necrotic pancreatic or peripancreatic tissue that tends to develop four weeks after the onset of acute necrotizing pancreatitis. When infected, it is managed initially by antibiotic therapy before drainage by endoscopic, percutaneous, or surgical means. This study aims to describe the morbidity, mortality, length of stay (LOS), and cost of care associated with open surgical, laparoscopic, and radiology-guided percutaneous drainage in adult patients with infected WOPN. Methods Using the Nationwide Inpatient Sample (NIS), patients aged 18 years and older discharged with the diagnosis of WOPN between January 1, 2016 and December 31, 2016 who underwent open, laparoscopic, or percutaneous drainage were included. Patients' characteristics including age, gender, and body mass index were reported. The primary endpoints were the mortality rate as well as length and cost of stay in each group. The secondary endpoint was the rate of procedural complications in each arm. Endpoints were reported and compared with studies assessing similar outcomes. Statistical Analysis System (SAS) statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the analysis. Results A total of 229 patients with the diagnosis of acute pancreatitis with infected necrosis were identified. Of these 229 patients, 27, 15, and 20 underwent open, laparoscopic, and percutaneous drainage, respectively. A total of eight studies were used for comparison of outcome variables. Mortality rate was found to be similar among comparison studies. LOS and costs varied widely among studies. There were significantly fewer pancreatic fistula and significantly more multi-organ failure complications as a result of open necrosectomy in the NIS study sample. Conclusion Overall, in analyzing the outcomes of patients undergoing intervention for infected WOPN through the 2016 NIS database, it appears that the database is representative of the majority of outcomes seen in similar clinical trials.

Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions.

BACKGROUND: Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis. METHODS: Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals. RESULTS: One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P < 0.001) and mRS >2 at last contact (OR 12.83, P < 0.001). Stenting treatment with conjunctive angioplasty had lower rates of death (OR 0.303, P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent. CONCLUSION: Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.

Lesion location, stability, and pretreatment management: factors affecting outcomes of endovascular treatment for vertebrobasilar atherosclerosis.

BACKGROUND AND PURPOSE: The proper role of endovascular treatment of cervicocerebral atherosclerosis is unclear. Posterior circulation disease has not been investigated as extensively as disease in the anterior circulation. In this study, we characterized the rates of technical success, transient ischemic attack, stroke, and death or disability, for both acute and elective endovascular treatment of atherosclerosis in the vertebrobasilar system. METHODS: We identified patients with atherosclerosis of the vertebrobasilar circulation who underwent endovascular intervention at our hospital through retrospective medical record review, and evaluated the association between lesion and treatment features and subsequent stroke, death, or disability at 30 days and 1 year. RESULTS: We identified 136 lesions in 122 patients, including 13 interventions for acute strokes. Technical success was achieved in 123 of 136 cases (90.4%). Elective procedures had higher rates of technical success (6.5% vs 15.4%, p=0.21) and better clinical outcomes. In multivariate analysis, intracranial lesions were associated with more disability (modified Rankin Scale score >2) at 30 days (OR 7.1, p=0.01) and 1 year (OR 10, p=0.03). Patients with non-hypoperfusion related symptoms had fewer strokes at follow-up at 1 year when treated after an asymptomatic interval of >10 days compared with those treated within 10 days of the presenting symptoms (OR 0.2, p=0.03). Statin treatment prior to intervention was associated with favorable outcomes across several examined endpoints. Preoperative antiplatelet treatment was associated with lower rates of disability at 30 days and 1 year (OR 0.1, p<0.01 and OR 0.07, p=0.01, respectively), and preoperative anticoagulation treatment was associated with higher rates of death at 30 days, particularly when prescribed for reasons other than atrial fibrillation (OR 6.4, p=0.01). CONCLUSIONS: Endovascular treatment of symptomatic vertebrobasilar atherosclerosis can be performed safely and with good outcomes. Technical results were better for those with extracranial disease while clinical outcomes were more favorable in those patients with non-progressive symptoms in the subacute period and those receiving statin therapy.