EUS-guided therapies for primary and secondary prophylaxis in gastric varices-An updated systematic review and meta-analysis.

Background and Objectives: Gastric varices (GVs) are associated with a higher risk of uncontrolled bleeding and death when compared with esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding primary prophylaxis continue to emerge. Recently, EUS-guided therapies have been used in GV bleeding. Methods: We conducted a comprehensive search of several major databases from inception to June 2022. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and rebleeding with EUS-guided therapy in primary and secondary prophylaxis. Overall adverse events and technical failures were assessed. Random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I2 % statistics. Results: Eighteen studies with 604 patients were included. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (confidence interval [CI], 81.1-95.2; I2 = 0). With combination EUS-glue and coil therapy, the rate was 95.4% (CI, 86.7%-98.5%; I2 = 0). Pooled rate of posttherapy GV bleeding was 4.9% (CI, 1.8%-12.4%; I2 = 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI, 86.8%-95.2%; I2 = 12). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 94.3% (CI, 88.9%-97.1%; I2 = 0), 95.5% (CI, 80.3%-99.1%; I2 = 0), and 88.7% (CI, 76%-95.1%; I2 = 14), respectively. Pooled rate of GV obliteration was 83.6% (CI, 71.5%-91.2%; I2 = 74). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 84.6% (CI, 75.9%-90.6%; I2 = 31), 92.3% (CI, 81.1%-97.1%; I2 = 0), and 84.5% (CI, 50.8%-96.7%; I2 = 75), respectively. Pooled rates of GV rebleeding and recurrence were 18.1% (CI, 13.1%-24.3%; I2 = 16) and 20.6% (CI, 9.3%-39.5%; I2 = 66), respectively. Conclusion: Our analysis shows that EUS-guided therapy for GVs is technically feasible and clinically successful in both primary and secondary prophylaxis of GV.

Fecal microbiota transplant delivered via invasive routes in irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) results in significant loss of quality of life. Management guidelines do not recommend fecal microbiota transplant (FMT) for IBS based on weak evidence as refined data is lacking. We performed a systematic review and meta-analysis to ascertain the pooled clinical outcomes of FMT in IBS, delivered via invasive routes. METHODS: Multiple databases were searched through January 2023 to identify studies that reported on FMT treatment in IBS by invasive routes. Standard meta-analysis methodology using the random-effects model was used. Heterogeneity was assessed by I2% and 95% predication interval. RESULTS: Five studies were included. As many as 377 IBS patients were assessed, of which 238 received FMT and 139 received placebo. One study used nasojejunal tubes, one esophagogastroduodenoscopy and three colonoscopy for FMT delivery. FMT via colonoscopy was performed as a one-time procedure instilled into the cecum. Two studies used 30 g of stool from a single universal donor and one study used 50-80 g of pooled donor feces. The pooled odds ratio of improvement in IBS symptoms with FMT was significantly better as compared to that of placebo OR = 2.9 (95% CI [1.6-5.2, I2 = 62%, p < 0.001]). This was true for studies that exclusively used colonoscopy (OR = 2.1 [1.1-4.2, p = 0.04]). In the FMT arm, 10 patients (10.6%) reported abdomen pain and worsening of symptoms with bloating and six patients (6.3%) reported diarrhea. CONCLUSION: FMT delivered via invasive routes, especially colonoscopy, demonstrated significant improvement in IBS symptoms. A single FMT consisting of 30 g or more of single universal donor feces instilled into the cecum is the predominant modality.

Cap-assisted endoscopic treatment of esophageal food bolus impaction and/or foreign body ingestion: a systematic review and meta-analysis.

Background: Esophageal food bolus and/or foreign body (FB) impaction is a common gastrointestinal emergency. This meta-analysis reports on the pooled outcomes of cap-assisted endoscopic removal of esophageal FB. Methods: We conducted a comprehensive search of several databases (inception to February 2022) to identify studies reporting on the use of a cap in the endoscopic treatment of esophageal FB ingestion. A random effects model was used to calculate the pooled odds ratio (OR) and mean difference (MD), and I2 values were used to assess the heterogeneity. Results: Six studies were analyzed that included 677 patients treated with cap-assisted and 694 with conventional endoscopy. The cap-assisted method demonstrated statistically significant superiority regarding technical success (pooled OR 7.1, 95% confidence interval [CI] 1.9-26.9; P=0.004), en bloc removal (pooled OR 26.6, 95%CI 17.6-40.2; P<0.001), as well as a significantly shorter procedure time (4.6 min, 95%CI -6.5 to -2.8; P<0.001), compared to conventional methods. Better technical success was achieved with the cap-assisted method performed under anesthesia (OR 8.7, 95%CI 1.6-47.7; P=0.01); however, a shorter procedure time was noted for the cap-assisted method without anesthesia (MD -1.5, 95%CI -2.7 to -0.4; P=0.01). Pooled adverse events were comparable. Pooled OR for mucosal tear was significantly lower with cap in food bolus impaction (OR 0.07, 95%CI 0.01-0.38; P=0.02). Conclusion: Cap-assisted endoscopic removal of esophageal FB is associated with better technical success and en bloc removal, and a shorter procedure time compared to conventional methods, with comparable adverse events.

Responses to mechanically and visually cued water waves in the nervous system of the medicinal leech.

Sensitivity to water waves is a key modality by which aquatic predators can detect and localize their prey. For one such predator - the medicinal leech, Hirudo verbana - behavioral responses to visual and mechanical cues from water waves are well documented. Here, we quantitatively characterized the response patterns of a multisensory interneuron, the S cell, to mechanically and visually cued water waves. As a function of frequency, the response profile of the S cell replicated key features of the behavioral prey localization profile in both visual and mechanical modalities. In terms of overall firing rate, the S cell response was not direction selective, and although the direction of spike propagation within the S cell system did follow the direction of wave propagation under certain circumstances, it is unlikely that downstream neuronal targets can use this information. Accordingly, we propose a role for the S cell in the detection of waves but not in the localization of their source. We demonstrated that neither the head brain nor the tail brain are required for the S cell to respond to visually cued water waves.

Endoscopic submucosal dissection of gastric tumors: A systematic review and meta-analysis.

AIM: To systematically review the medical literature in order to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD). METHODS: We performed a comprehensive literature search of MEDLINE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of gastric ESD. RESULTS: Twenty-nine thousand five hundred and six tumors in 27155 patients (31% female) who underwent gastric ESD between 1999 and 2014 were included in this study. R0 resection rate was 90% (95%CI: 87%-92%) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in region (P = 0.02) and sample size (P = 0.04). Endoscopic en bloc and curative resection rates were 94% (95%CI: 93%-96%) and 86% (95%CI: 83%-89%) respectively. The rate of immediate and delayed perforation rates were 2.7% (95%CI: 2.1%-3.3%) and 0.39% (95%CI: 0.06%-2.4%) respectively while rates of immediate and delayed major bleeding were 2.9% (95%CI: 1.3-6.6) and 3.6% (95%CI: 3.1%-4.3%). After an average follow-up of about 30 mo post-operative, the rate of tumor recurrence was 0.02% (95%CI: 0.001-1.4) among those with R0 resection and 7.7% (95%CI: 3.6%-16%) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 0.75% (95%CI: 0.42%-1.3%). CONCLUSION: Our meta-analysis, the largest and most comprehensive assessment of gastric ESD till date, showed that gastric ESD is safe and effective for gastric tumors and warrants consideration as first line therapy when an expert operator is available.

Surgical site infections in genital reconstruction surgery for gender reassignment, Detroit: 1984-2008.

BACKGROUND: Gender reassignment surgery (i.e., male-to-female or female-to-male) entails a series of complex surgical procedures. We conducted a study to explore epidemiologic characteristics of patients who underwent genital reconstruction operations as components of gender reassignment and to analyze risk factors for surgical-site infections (SSIs) following these operations. METHODS: The study was a retrospective cohort study conducted from 1984-2008 at Harper University Hospital, a tertiary hospital with 625 beds in Detroit, Michigan. Surgical site infection was defined according to established criteria. RESULTS: Records were available for 82 patients who underwent a total of 1,383 operations as part of genital-reconstruction processes. Thirty-nine (47.6%) of the patients underwent female-to-male reassignment (FTM) and 43 (52.4%) underwent male-to-female reassignment (MTF). The average age of the study cohort was 39.5±9.8 y. Of the patients in the cohort, 56 (68.3%) were Caucasian and 67 (81.7%) were single. The average number of operative encounters per patient was 11.8±4.6 for FTM and 4.9±2.4 for MTF. Forty-three (52.4%) patients developed an SSI at least once during their genital reconstruction process, of whom 34 (87%) were in the FTM group and nine (21%) in the MTF group (p<0.001). Staphylococci were the most common pathogens (61%) isolated in these infections, followed by Enterobacteriaceae (50%), Enterococcus (39%), and Pseudomonas aeruginosa (33.3%). Surgical site infection was associated independently with an increased frequency of operative procedures and operating room encounters. CONCLUSIONS: More than 50% of patients who underwent genital reconstruction operations developed an SSI at some point during the genital reconstruction process. Surgical site infections are more common in FTM than in MTF reconstruction operations, and for both FTM and MTF, SSIs are associated independently with an increased frequency of total operative procedures and encounters.