EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video).

BACKGROUND AND AIMS: Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. METHODS: This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. RESULTS: A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. CONCLUSIONS: This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

Efficacy and Safety of Gastric Per-Oral Endoscopic Myotomy (G-POEM): A Systematic Review and Meta-Analysis.

BACKGROUND: Gastric per-oral endoscopic myotomy (G-POEM) is an innovative treatment that has become increasingly utilized for patients with refractory gastroparesis. The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of G-POEM for the treatment of gastroparesis. METHODS: Individualized search strategies were developed through February 2021 in accordance with the PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions and mean difference preprocedure and postprocedure with rates estimated using random effects models. Measured outcomes included technical success, clinical success, improvement in gastroparesis cardinal symptom index (GCSI), change in gastric emptying rate, alterations in impedance planimetry (functional lumen imaging probe [FLIP]) assessment, and adverse events. RESULTS: A total of 20 studies (n=797 patients; 67.41% female) were included. The mean age was 48.92±11.61 y, with an average duration of 4.24±1.11 y since gastroparesis diagnosis. Technical success was 98.47% [(95% CI: 97.14, 99.19);I2=0.00] with a mean myotomy length of 3.78±1.16 cm. In terms of clinical success, mean preprocedure GCSI scores were 3.38±0.37 and improved significantly postprocedure [weighted mean difference -1.56 (95% CI: -1.89 to -1.24); I2=82.53; P<0.001]. Gastric retention after 4 hours demonstrated ~50% improvement (preprocedure 43.08±9.24% versus postprocedure 22.97±10.19%; P<0.001). FLIP assessment with 40 mL and 50 mL balloons demonstrated a significant increase in diameter, distensibility index, and cross-sectional area postprocedure (all P<0.05). Procedure-associated adverse events occurred among 10.92% [(95% CI 5.09 to 19.32); I2=82.85] of patients. CONCLUSION: G-POEM appears safe and highly effective for the treatment of patients with refractory gastroparesis regardless of symptom predominance or etiology.

A Comprehensive Analysis of Reported Adverse Events and Device Failures Associated with Esophageal Self-Expandable Metal Stents: An FDA MAUDE Database Study.

INTRODUCTION: Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05. RESULTS: During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001). CONCLUSION: Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.

Structured training program on confocal laser endomicroscopy for pancreatic cystic lesions: a multicenter prospective study among early-career endosonographers (with video).

BACKGROUND AND AIMS: Data on how to teach endosonographers needle-based confocal laser endomicroscopy (nCLE)-guided histologic diagnosis of pancreatic cystic lesions (PCLs) are limited. Hence, we developed and tested a structured educational program to train early-career endosonographers in nCLE-guided diagnosis of PCLs. METHODS: Twenty-one early-career nCLE-naïve endosonographers watched a teaching module outlining nCLE criteria for diagnosing PCLs. Participants then reviewed 80 high-yield nCLE videos, recorded diagnoses, and received expert feedback (phase 1). Observers were then randomized to a refresher feedback session or self-learning at 4 weeks. Eight weeks after training, participants independently assessed the same 80 nCLE videos without feedback and provided histologic predictions (phase 2). Diagnostic performance of nCLE to differentiate mucinous versus nonmucinous PCLs and to diagnose specific subtypes were analyzed using histopathology as the criterion standard. Learning curves were determined using cumulative sum analysis. RESULTS: Accuracy and diagnostic confidence for differentiating mucinous versus nonmucinous PCLs improved as endosonographers progressed through nCLE videos in phase 1 (P < .001). Similar trends were observed with the diagnosis of PCL subtypes. Most participants achieved competency interpreting nCLE, requiring a median of 38 assessments (range, 9-67). During phase 2, participants independently differentiated PCLs with high accuracy (89%), high confidence (83%), and substantial interobserver agreement (κ = .63). Accuracy for nCLE-guided PCL subtype diagnoses ranged from 82% to 96%. The learned nCLE skills did not deteriorate at 8 weeks and were not impacted by a refresher session. CONCLUSIONS: We developed a practical, effective, and durable educational intervention to train early-career endosonographers in nCLE-guided diagnosis of PCLs.

Endoscopic full-thickness resection of colorectal lesions: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) is a novel endoscopic technique for the resection of GI lesions not amenable to standard endoscopic therapy. The primary aim of this study was to perform a systematic review and meta-analysis to evaluate EFTR for the resection of colorectal lesions. METHODS: Individualized searches were developed through October 2020 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Random-effects models were used to determine pooled technical success, margin-negative (R0) resection, adverse events, procedure duration, and rate of recurrence at follow-up. Subgroup analysis was used to assess the impact of specific procedure techniques and regression analyses to determine influence of lesion size. Heterogeneity was assessed with I2 statistics and publication bias by funnel plots using Egger and Begg tests. RESULTS: Fourteen studies (1936 subjects; 39.6% women) were included. Most EFTR lesions were located in the colon (75.8%) with the remaining in the rectum. Mean procedure duration was 45.4 ± 11.4 minutes. Pooled technical success was 87.6% (95% confidence interval [CI], 85.1-89.8; I2 = 33), R0 resection rate was 78.8% (95% CI, 75.7-81.5; I2 = 33), procedure-associated adverse events occurred in 12.2% (95% CI, 9.3-15.9; I2 = 61), and recurrence rate was 12.6% (95% CI, 11.1-14.4; I2 = 0) over an average weighted follow-up of 20.1 ± 3.8 weeks. Regression analyses revealed significantly lower R0 resection (odds ratio, .3; 95% CI, .2-.6; I2 = 61; P = .0003) and higher overall procedure-associated adverse event rates (odds ratio, 3.5; 95% CI, 1.8-7.2; I2 = 55; P = .0004) for lesions >20 mm. CONCLUSIONS: EFTR overall appears to be an effective modality with high technical success and R0 resection rate with a relatively low risk of adverse events and recurrence, with greatest success when lesions are <20 mm.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy for the palliation of gastric outlet obstruction in patients with peritoneal carcinomatosis.

BACKGROUND : Gastric outlet obstruction (GOO) with peritoneal carcinomatosis presents a technical challenge. Surgical gastrojejunostomy (SGJ) or enteral stenting have been the standard of care; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a favorable alternative. Few data exist that compare these techniques in the setting of peritoneal carcinomatosis. METHODS : This single-center retrospective cohort study included 25 EUS-GE and 27 SGJ consecutive patients. Baseline demographics, cancer diagnosis and stage, clinical and technical success, adverse events, and obstruction recurrence data were collected. The primary outcome was the technical success comparison; secondary outcome was the adverse event rate comparison. Rates were compared with standard statistical tests. RESULTS : Mean age, obstruction location, and symptoms were similar between the groups. The EUS-GE group had more advanced disease (clinical stage 4, 100 % vs. 67 %; P = 0.006) and higher American Society of Anesthesiologists classification (class 3-4, 92 % vs. 50 %; P = 0.004). The technical success rate was 100 % in both groups (P > 0.99) and the adverse event rate was lower for EUS-GE (8 % vs. 41 %; P = 0.01). Clinical success was 88 % for EUS-GE and 85 % for SGJ (P > 0.99) and recurrent obstruction was lower with EUS-GE (28 % vs. 41 %; P = 0.13). The EUS-GE group had shorter procedure duration, length of stay, and time to chemotherapy resumption than the SGJ group. CONCLUSIONS : Although the EUS-GE group was older, with more comorbidity and advanced stages, the technical success rate was similar to SGJ and it had significantly fewer adverse events. EUS-GE is a safe and effective option for the management of malignant GOO with peritoneal carcinomatosis.

Variceal Bleeding: Beyond Banding.

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Endoscopic revision of gastrojejunal anastomosis for the treatment of dumping syndrome in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis.

BACKGROUND: Dumping syndrome is a known complication of Roux-en-Y gastric bypass (RYGB). Recently, endoscopic gastrojejunal anastomosis (GJA) revision has been employed as a treatment option. The primary aim of this study was to perform a systematic review and meta-analysis for the role of endoscopic GJA revision in patients with RYGB for the treatment of dumping syndrome. METHODS: Search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception through December 2020 in accordance with PRISMA and MOOSE guidelines. Pooled proportions with rates estimated using random effects models were used. Outcomes included pooled technical success, clinical success, adverse events, and rate of reintervention. Heterogeneity was assessed with I2 statistics and publication bias by funnel plot using Egger and Begg tests. RESULTS: Six studies (n = 263 patients; 60.25% female) were included (1 prospective and 5 retrospective). Mean age was 46.27 ± 2.54 years. Average patient weight was 95.59 ± 4.78 kg, BMI of 41.43 ± 3.07 kg/m2, and pre-procedure GJA size of 32.23 ± 8.68 mm. Pooled technical and clinical success was 98.15% and 89.5%. Among studies reporting Sigstad scores, endoscopic GJA revision resulted in a significant improvement [mean Sigstad score difference of - 9.96 (95% CI, - 19.951 to - 0.975); P < 0.03]. Mean procedure time was 37.12 ± 10.40 min with an intra-procedural adverse event rate of 2.42%. Over a mean follow-up of 8.03 ± 6.87 months, post-procedure adverse events occurred in 2.96% of patients with a reintervention rate of 11.54%. CONCLUSION: This systematic review and meta-analysis suggests that endoscopic GJA revision appears an effective and safe treatment for dumping syndrome.

Primary obesity surgery endoluminal (POSE) for the treatment of obesity: a systematic review and meta-analysis.

BACKGROUND: Primary obesity surgery endoluminal (POSE) utilizes an incision-less operating platform system to create full-thickness plications in the gastric fundus and body (original POSE). Many studies have demonstrated the safety and efficacy of original POSE for the treatment of obesity. OBJECTIVE: We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to evaluate the outcomes of original POSE per the ASGE task force thresholds. METHODS: Bibliographic databases were systematically searched for studies assessing the outcomes of POSE for the treatment of obesity. All randomized controlled trials (RCTs) and observational studies that assessed outcomes of POSE were included. Studies were included if they reported percent total weight loss (%TWL) or percent excess weight loss (%EWL) and the incidence of serious adverse events (SAE). RESULTS: A total of seven studies with 613 patients were included. Two included studies were RCTs, while the remaining were observational studies. Pooled mean %EWL at 3-6 months and 12-15 months were 42.62 (95% CI 37.56-47.68) and 48.86 (95% CI 42.31-55.41), respectively. Pooled mean %TWL at 3-6 months and 12-15 months was 13.45 (95% CI 8.93-17.97) and 12.68 (95% CI 8.13-17.23), respectively. Subgroup analysis of two RCTs showed that weight loss at 1 year was significantly higher in POSE patients (%EWL difference in means 19.45 (95% CI 4.65-34.24, p value = 0.01). The overall incidence of serious adverse events was only 2.84% and included GI bleeding, extra-gastric bleeding, hepatic abscess, severe pain, severe nausea, and severe vomiting. The mean number of total anchors placed in the fundus and body was 13.18 (95% CI 11.77-14.58), and the mean procedure time was 44.55 min (95% CI 36.44-52.65). CONCLUSION: POSE, a minimally invasive endoscopic bariatric therapy, is a safe and effective modality for the treatment of obesity. The outcomes of POSE meet and surpass the ASGE joint task force thresholds. Future studies should evaluate newer versions of this procedure that emphasize gastric body plication sparing the fundus.

How Do Presenting Symptoms and Outcomes Differ by Race/Ethnicity Among Hospitalized Patients With Coronavirus Disease 2019 Infection? Experience in Massachusetts.

BACKGROUND: Population-based literature suggests severe acute respiratory syndrome coronavirus 2 infection may disproportionately affect racial/ethnic minorities; however, patient-level observations of hospitalization outcomes by race/ethnicity are limited. Our aim in this study was to characterize coronavirus disease 2019 (COVID-19)-associated morbidity and in-hospital mortality by race/ethnicity. METHODS: This was a retrospective analysis of 9 Massachusetts hospitals including all consecutive adult patients hospitalized with laboratory-confirmed COVID-19. Measured outcomes were assessed and compared by patient-reported race/ethnicity, classified as white, black, Latinx, Asian, or other. Student t test, Fischer exact test, and multivariable regression analyses were performed. RESULTS: A total of 379 patients (aged 62.9 ± 16.5 years; 55.7% men) with confirmed COVID-19 were included (49.9% white, 13.7% black, 29.8% Latinx, 3.7% Asian), of which 376 (99.2%) were insured (34.3% private, 41.2% public, 23.8% public with supplement). Latinx patients were younger, had fewer cardiopulmonary disorders, were more likely to be obese, more frequently reported fever and myalgia, and had lower D-dimer levels compared with white patients (P < .05). On multivariable analysis controlling for age, gender, obesity, cardiopulmonary comorbidities, hypertension, and diabetes, no significant differences in in-hospital mortality, intensive care unit admission, or mechanical ventilation by race/ethnicity were found. Diabetes was a significant predictor for mechanical ventilation (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.11-3.23), while older age was a predictor of in-hospital mortality (OR, 4.18; 95% CI, 1.94-9.04). CONCLUSIONS: In this multicenter cohort of hospitalized COVID-19 patients in the largest health system in Massachusetts, there was no association between race/ethnicity and clinically relevant hospitalization outcomes, including in-hospital mortality, after controlling for key demographic/clinical characteristics. These findings serve to refute suggestions that certain races/ethnicities may be biologically predisposed to poorer COVID-19 outcomes.

Hybrid endoscopic submucosal dissection (ESD) compared with conventional ESD for colorectal lesions: a systematic review and meta-analysis.

BACKGROUND: Hybrid endoscopic submucosal dissection (ESD) is increasingly utilized to overcome the complexity of conventional ESD. This systematic review and meta-analysis evaluated the efficacy and safety of hybrid ESD for treatment of colorectal lesions. METHODS: Search strategies were developed in accordance with PRISMA guidelines. Pooled proportions were calculated with rates estimated using random effects models. Measured outcomes included en bloc resection, procedure-associated complications, recurrence, and need for surgery. Subgroup analyses were performed to compare effectiveness of conventional versus hybrid ESD. RESULTS: 16 studies (751 patients) were included with a mean (standard deviation [SD]) lesion size of 27.96 (10.55) mm. En bloc resection rate was 81.63 % (95 % confidence interval [CI] 72.07 - 88.44; I2  = 80.89). Complications, recurrences, and need for surgery occurred in 7.74 % (95 %CI 4.78 - 12.31; I2  = 65.84), 4.52 % (95 %CI 1.40 - 13.65; I2  = 76.81), and 3.64 % (95 %CI 1.76 - 7.37; I2  = 15.52), respectively. Mean procedure duration was 48.83 (22.37) minutes. On subgroup analyses comparing outcomes for conventional (n = 1703) versus hybrid ESD (n = 497), procedure duration was significantly shorter for hybrid ESD (mean difference 18.45 minutes; P = 0.003), with lower complication rates (P = 0.04); however, hybrid ESD had lower en bloc resection rates (P < 0.001). There was no difference in rates of recurrence or surgery (P > 0.05). CONCLUSION: While hybrid ESD was safe and effective for removal of colorectal lesions, with shorter procedure duration, fewer complications, and no difference in recurrence versus conventional ESD, hybrid ESD was associated with a lower en bloc resection rate.

Endoscopic gallbladder drainage for symptomatic gallbladder disease: a cumulative systematic review meta-analysis.

BACKGROUND: Endoscopic ultrasound (EUS)-guided transmural or endoscopic retrograde cholangiography (ERC)-based transpapillary drainage may provide alternative treatment strategies for high-risk surgical candidates with symptomatic gallbladder (GB) disease. The primary aim of this study was to perform a systematic review and meta-analysis to investigate the efficacy and safety of endoscopic GB drainage for patients with symptomatic GB disease. METHODS: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed in accordance with PRISMA and MOOSE guidelines. Pooled proportions were calculated for measured outcomes including technical success, clinical success, adverse event rate, recurrence rate, and rate of reintervention. Subgroup analyses were performed for transmural versus transpapillary, transmural lumen apposing stent (LAMS), and comparison to percutaneous transhepatic drainage. Heterogeneity was assessed with I2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. RESULTS: Thirty-six studies (n = 1538) were included. Overall, endoscopic GB drainage achieved a technical and clinical success of 87.33% [(95% CI 84.42-89.77); I2 = 39.55] and 84.16% [(95% CI 80.30-87.38); I2 = 52.61], with an adverse event rate of 11.00% [(95% CI 9.25-13.03); I2 = 7.08]. On subgroup analyses, EUS-guided transmural compared to ERC-assisted transpapillary drainage resulted in higher technical and clinical success rates [OR 3.91 (95% CI 1.52-10.09); P = 0.005 and OR 4.59 (95% CI 1.84-11.46); P = 0.001] and lower recurrence rate [OR 0.17 (95% CI 0.06-0.52); P = 0.002]. Among EUS-guided LAMS studies, technical success was 94.65% [(95% CI 91.54-96.67); I2 = 0.00], clinical success was 92.06% [(95% CI 88.65-94.51); I2 = 0.00], and adverse event rate was 11.71% [(95% CI 8.92-15.23); I2 = 0.00]. Compared to percutaneous drainage, EUS-guided drainage possessed a similar efficacy and safety with significantly lower rate of reintervention [OR 0.05 (95% CI 0.02-0.13); P < 0.001]. DISCUSSION: Endoscopic GB drainage is a safe and effective treatment for high-risk surgical candidates with symptomatic GB disease. EUS-guided transmural drainage is superior to transpapillary drainage and associated with a lower rate of reintervention compared to percutaneous transhepatic drainage.

Endoscopic submucosal dissection (ESD) versus transanal endoscopic microsurgery (TEM) for treatment of rectal tumors: a comparative systematic review and meta-analysis.

BACKGROUND: While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors. METHODS: Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R0) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I2 statistics, and publication bias by funnel plot using Egger and Begg tests. RESULTS: Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I2 = 0.00%] and R0 resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I2 = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I2 = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I2 = 0.00%]. CONCLUSION: ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.

Efficacy of digital single-operator cholangioscopy in the visual interpretation of indeterminate biliary strictures: a systematic review and meta-analysis.

OBJECTIVE: Indeterminate biliary strictures remain a significant diagnostic challenge. Digital single-operator cholangioscopy (D-SOC) incorporates digital imaging which enables higher resolution for better visualization and diagnosis of biliary pathology. We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to determine the efficacy of D-SOC in the visual interpretation of indeterminate biliary strictures. MATERIAL AND METHODS: Electronic searches were performed using Medline (PubMed), EMBASE, and Cochrane Library. All D-SOC studies that reported the diagnostic performance in visual interpretation of indeterminate biliary strictures and biliary malignancies were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 was used to evaluate the quality of the included studies. All data were extracted and pooled to construct a 2 × 2 table. The visual interpretation of D-SOC was compared to resected surgical specimens or clinical follow-up in the included patients. Pooled sensitivity, specificity, positive predictive value, negative predictive value, prevalence, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and diagnostic odds ratio (OR) were calculated. The summarized receiver operating characteristic (SROC) curve corresponding with the area under the curve (AUC) was also analyzed. RESULTS: The search yielded 465 citations. Of these, only six studies with a total of 283 procedures met inclusion criteria and were included in the meta-analysis. The overall pooled sensitivity and specificity of D-SOC in the visual interpretation of biliary malignancies was 94% (95% CI 89-97) and 95% (95%CI 90-98), respectively, while +LR, -LR, diagnostic OR, and AUC were 15.20 (95%CI 5.21-44.33), 0.08 (95%CI 0.04-0.14), 308.83 (95%CI 106.46-872.82), and 0.983, respectively. The heterogeneity among 6 included studies was moderate for specificity (I2 = 0.51) and low for sensitivity (I2 = 0.17) and diagnostic OR (I2 = 0.00). CONCLUSION: D-SOC is associated with high sensitivity and specificity in the visual interpretation of indeterminate biliary strictures and malignancies. D-SOC should be considered routinely in the diagnostic workup of indeterminate biliary lesions.

Gastric variceal bleeding.

PURPOSE OF REVIEW: There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence. RECENT FINDINGS: In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions. SUMMARY: Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.

WITHDRAWN: Clinical outcomes of EUS-guided coil embolization versus traditional cyanoacrylate injection for treatment of gastric varices (with video).

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