Lumen-apposing metal stents with or without coaxial plastic stent placement for the management of pancreatic fluid collections.

BACKGROUND AND AIMS: Coaxial double-pigtail plastic stent (DPPS) placement is often performed within lumen-apposing metal stents (LAMSs) for drainage of pancreatic fluid collections (PFCs) to prevent adverse events (AEs) such as stent occlusion and bleeding. This study compares the safety and outcomes of LAMSs alone versus LAMSs with coaxial DPPSs for PFC management. METHODS: Patients undergoing drainage of a PFC with LAMSs were retrospectively identified and categorized as LAMS or LAMS/DPPS based on initial drainage strategy. The AE rate, AE type, and clinical success were extracted by chart review. RESULTS: One hundred eighty-five individuals (83 LAMS, 102 LAMS/DPPS) were identified. No significant differences were found in rates of clinical success (75.9% LAMS vs 69.6% LAMS/DDPS, P = .34) or overall AEs (15.7% LAMS vs 15.7% LAMS/DPPS, P = .825). CONCLUSIONS: In this comparative single-center study, placement of a coaxial DPPS for drainage of PFCs with LAMSs did not affect rates of AEs or clinical success.

Effect of endoscopic sleeve gastroplasty on gastric emptying, motility and hormones: a comparative prospective study.

OBJECTIVE: Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG. DESIGN: A priori-designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss. RESULTS: 36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG. CONCLUSION: ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity. TRIAL REGISTRATION NUMBER: NCT03406975.

Prospective Multicenter Study of the Primary Obesity Surgery Endoluminal (POSE 2.0) Procedure for Treatment of Obesity.

BACKGROUND & AIMS: The Primary Obesity Surgery Endoluminal (POSE) 2.0 procedure involves a novel pattern of full-thickness gastric body plications to shorten and narrow the stomach using durable suture anchor pairs. Our prospective, multicenter trial examined the safety, efficacy, durability, and physiologic effects of POSE 2.0 in adults with obesity. METHODS: Adults with obesity underwent POSE 2.0 at 3 centers. Primary outcomes were percent total body weight loss (%TBWL) and proportion of patients achieving >5% TBWL at 12 months. Secondary outcomes included change in obesity comorbidities, satiety, quality of life at 6 months, and durability of plications at 12 and 24 months. Subjects were followed for adverse events throughout the study duration. RESULTS: 44 patients (61% female; mean age, 45 ± 9.7 years; mean body mass index, 37 ± 2.1 kg/m2) were enrolled. This procedure used an average of 19 suture anchor pairs, with a mean duration of 37 ± 11 minutes, and was technically successful in all subjects. Mean %TBWL at 12 months was 15.7% ± 6.8%. At 12 months, %TBWL >5%, >10%, and >15% was achieved in 98%, 86%, and 58% of patients, respectively. Improvements in lipid profile, liver biochemistries, and hepatic steatosis were seen at 6 months. Improvements in hepatic steatosis persisted for 24 months in a subgroup of patients (P < .01). POSE 2.0 reduced maximum tolerated meal volume (P = .03) and was associated with increased fullness (P < .01) and improved eating behavior (P < .01) at 6 months. Impact of weight on quality-of-life questionnaire improved at 6 months (2.23 vs 1.23; P < .01). Repeat assessment at 24 months (n = 26) showed fully intact plications. No serious adverse events occurred. CONCLUSION: POSE 2.0 is an effective and durable endoscopic bariatric therapy which may influence physiologic pathways impacting satiety. Larger comparative studies are needed to further elucidate these initial findings. CLINICALTRIALS: gov Identifier: NCT03721731.

Lumen-apposing metal stents for the treatment of benign gastrointestinal tract strictures: a single-center experience and proposed treatment algorithm.

BACKGROUND: Lumen-apposing metal stents (LAMS) are an alternative therapeutic option for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluate the safety and efficacy of LAMS for the management of benign GI strictures. METHODS: Consecutive patients who underwent a LAMS placement for benign luminal GI strictures at a tertiary care center between January 2014 and July 2021 were reviewed. Primary outcomes included technical success, early clinical success, and adverse events (AEs). Other outcomes included rates of stent migration and re-intervention after LAMS removal. RESULTS: One hundred and nine patients who underwent 128 LAMS placements (67.9% female, mean age of 54.3 ± 14.2 years) were included, and 70.6% of the patients had failed prior endoscopic treatments. The majority of strictures (83.5%) were anastomotic, and the most common stricture site was the gastrojejunal anastomosis (65.9%). Technical success was achieved in 100% of procedures, while early clinical success was achieved in 98.4%. The overall stent-related AE rate was 25%. The migration rate was 27.3% (35/128). Of these, five stents were successfully repositioned endoscopically. The median stent dwell time was 119 days [interquartile range (IQR) 68-189 days], and the median follow-up duration was 668.5 days [IQR: 285.5-1441.5 days]. The re-intervention rate after LAMS removal was 58.3%. CONCLUSIONS: LAMS is an effective therapeutic option for benign GI strictures, offering high technical and early clinical success. However, the re-intervention rate after LAMS removal was high. In select cases, using LAMS placement as destination therapy with close surveillance is a reasonable option.

Endoscopic suturing and plication in the stomach for weight loss.

The prevalence of obesity has been increasing on a global scale. However, less than 1% of patients eligible for bariatric surgery actually undergo weight loss surgery. Endobariatric therapies (EBTs) have emerged to bridge the obesity treatment gap, as they are less invasive, highly effective, and more broadly applicable to patients with mild to moderate obesity. Endoscopic sleeve gastroplasty and primary obesity surgery endoluminal are the two most promising EBTs, altering stomach physiologies mimicking bariatric surgery. This review focuses on these two EBT approaches.

Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS: Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS: Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS: R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.

Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up.

BACKGROUND: In selected cases of post-bariatric leaks and fistulas, endoscopy is an initial treatment modality. Management can be complex and require multiple endoscopic sessions with varying degrees of success. Our aim was to describe our tertiary care experience on endoscopy management of refractory post-bariatric leaks and fistulas. METHODS: Patients with post-bariatric leaks and/or fistulas who failed an initial endoscopic intervention were included. Endoscopic treatments were classified into four strategies: (1) closure management, (2) active drainage, (3) passive drainage, and (4) plugging. Clinical success and adverse events were assessed. RESULTS: A total of 25 patients (mean age = 45.3 ± 11.8 years and 56% female) were included. Clinical success was achieved in 20 patients (80%) with a mean of 3.0 ± 1.5 procedures and a median time to healing of 114.5 (53-210.3) days. Closure and plugging were the main successful strategies used for early and acute leaks/fistulas, while drainage was for late and chronic leaks/fistulas. Adverse events were observed in 13 patients (52%) with one serious adverse event. Patients with fistulas had a lower success rate (72.2% vs. 100%, P = 0.052). Of those with clinical failure (n = 5), four underwent reconstructive surgery, eventually led to success in 3 patients. The other one died of septic shock related to a complicated fistula. CONCLUSIONS: Complex multi-modality endoscopic management ultimately achieved clinical success in most cases of refractory leaks/fistulas post-bariatric with an acceptable safety profile. However, a close follow-up to detect the development of long-term failure is warranted. These patients should be referred to a specialized bariatric center with expertise in bariatric endoscopy and surgery.

Endoscopic full-thickness suturing plus argon plasma mucosal coagulation versus argon plasma mucosal coagulation alone for weight regain after gastric bypass: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Endoscopic transoral outlet reduction (TORe) has been used to manage weight regain after Roux-en-Y gastric bypass. We conducted a meta-analysis to summarize the efficacy and safety of the two most commonly used techniques: full-thickness suturing plus argon plasma mucosal coagulation (ft-TORe) and argon plasma mucosal coagulation alone (APMC-TORe). METHODS: A literature search of publication databases was performed from their inception to February 2020 for relevant studies. The outcomes of interest were percentage total body weight loss, gastrojejunal anastomosis (GJA) diameter, and adverse events (AEs). The pooled effect estimates were analyzed using a random-effects model. Meta-regression was conducted to identify associations between GJA diameter and weight loss. RESULTS: Nine ft-TORe (n = 737) and 7 APMC-TORe (n = 888) studies were included. APMC-TORe was performed as a series of sessions (mean number of sessions ranging from 1.2 to 3), whereas ft-TORe was mostly performed as a single session. Percentage total body weight loss was 8.0% (95% confidence interval [CI], 6.3%-9.7%), 9.5% (95% CI, 8.1%-11.0%), and 5.8% (95% CI, 4.3%-7.1%) after ft-TORe and 9.0% (95% CI, 4.1%-13.9%), 10.2% (95% CI, 8.4%-12.1%), and 9.5% (95% CI, 5.7%-13.2%) after APMC-TORe at 3, 6, and 12 months, respectively, with no weight-loss difference at 3 and 6 months (P > .05). Only one severe AE was observed after APMC-TORe and none after ft-TORe. Stricture formation was the most common AE (ft-TORe 3.3% and APMC-TORe 4.8%, P = .38). All were successfully treated by endoscopic dilation or conservative treatment. Smaller aperture of the post-TORe GJA and greater change in the GJA diameter correlated with greater weight loss in APMC-TORe and numerical trends in ft-TORe. CONCLUSIONS: This meta-analysis demonstrates that both ft-TORe and APMC-TORe offer significant and comparable weight-loss outcomes with a high and comparable safety profile. However, APMC-TORe typically required multiple endoscopic sessions. Identifying a goal for the final and change in GJA diameter could be useful treatment targets.

Whey Protein Supplementation Improves Body Composition and Cardiovascular Risk Factors in Overweight and Obese Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous literature shows possible benefits of whey protein supplementation in promoting weight loss. However, most studies do not have enough power to show beneficial effects on body composition and cardiovascular disease (CVD) risk factors. This meta-analysis evaluated effects of whey protein in individuals who are overweight and obese. METHODS: We comprehensively searched the databases of MEDLINE, Embase, and Cochrane databases. The inclusion criteria were published randomized control trials (RCTs) comparing whey protein supplementation to placebo or controls in individuals who are overweight or obese. The primary outcome was the differences in the change in body composition (body weight, waist circumference, total fat mass, body lean mass). We also examined the changes in CVD risk factors as secondary outcomes. We calculated pooled mean difference (MD) with 95% confidence intervals (CIs) using a random effects model. RESULTS: Nine RCTs were included in the meta-analysis. There was a significant reduction of body weight (MD = 0.56, 95% CI: 0.30-0.81), lean mass (MD = 0.77, 95% CI: 0.59-0.96), and fat mass (MD = 1.12, 95% CI: 0.77-1.47) favoring the whey protein group. There were improvements in multiple CVD risk factors including levels of systolic blood pressure, diastolic blood pressure, glucose, high-density lipoprotein, and total cholesterol (all p values <0.05). CONCLUSIONS: Whey protein supplementation seems to improve body weight, total fat mass, and some CVD risk factors in overweight and obese patients. Further studies regarding optimal dosage and duration of whey protein supplementation would be helpful to assess potential favorable effects in individuals who are overweight or obese.

Obesity and the Risk of Colonic Diverticulosis: A Meta-analysis.

BACKGROUND: The possible relationship between obesity and the risk of colonic diverticulosis has been suggested by recent epidemiologic studies, although the results were inconsistent. OBJECTIVE: This systematic review and meta-analysis was conducted to summarize all of the available data. DATA SOURCES: A comprehensive literature review was conducted using the MEDLINE and EMBASE databases through January 2017. STUDY SELECTION: Studies that compared the risk of colonic diverticulosis among subjects with obesity versus those without obesity were included. MAIN OUTCOME MEASURES: Effect estimates from each study were extracted and combined together using a random-effect, generic inverse variance method. RESULTS: Of 2989 potentially eligible articles, 10 studies (9 cross-sectional studies and 1 prospective cohort study) with 53,520 participants met the eligibility criteria and were included in the meta-analysis. The risk of colonic diverticulosis in obese subjects was significantly higher than in those without obesity, with a pooled OR of 1.41 (95% CI, 1.20-1.65). The statistical heterogeneity was high, with an I of 75%. LIMITATIONS: High statistical heterogeneity and publication bias in favor of positive studies may have been present in this meta-analysis. CONCLUSIONS: A significant association between colonic diverticulosis and obesity was shown in this study. However, additional studies are still required to determine the causality. See Video Abstract at http://links.lww.com/DCR/A500.

Helicobacter pylori and Risk of Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis.

BACKGROUND/OBJECTIVES: Helicobacter pylori (H. pylori) is the most common chronic bacterial infection. Patients with H. pylori infection may be at an increased risk of nonalcoholic fatty liver disease (NAFLD) because of chronic inflammation and insulin resistance. Several epidemiologic studies attempting to determine this risk have yielded inconsistent results. This meta-analysis was conducted with the aims to summarize all available evidence and estimate the risk of NAFLD in patients with H. pylori infection. METHODS: A literature search was performed using MEDLINE and EMBASE database from inception to June 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of NAFLD among patients with H. pylori infection versus without H. pylori infection were included. Pooled odds ratios and 95% confidence intervals were calculated using a random-effect, generic inverse variance method. RESULTS: Six studies met our eligibility criteria and were included in this analysis. We found a statistically significant increased risk of NAFLD among patients with H. pylori infection with the pooled odds ratios of 1.21 (95% confidence interval, 1.07-1.37). The statistical heterogeneity was low with an I of 49%. CONCLUSIONS: A significantly increased risk of NAFLD among patients with H. pylori infection was demonstrated in this meta-analysis. Further studies are required to clarify how this risk should be addressed in clinical practice.

Risk factors associated with longer cecal intubation time: a systematic review and meta-analysis.

PURPOSE: Cecal intubation time (CIT) is an indicator for difficult colonoscopy which is associated with patients' unpleasant experience as well as increased risk of complications. Several studies have attempted to identify predictors for prolonged CIT but those studies tended to be small which gave rise to inconsistent and underpowered results. This systematic review and meta-analysis was conducted to summarize all available data. METHODS: MEDLINE and EMBASE databases were searched through November 2017 for studies that investigated the factors for prolonged CIT. Only factors that were reported by at least three studies were included in the meta-analyses. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated using random effects model. The between-study heterogeneity of effect size was quantified using the Q statistic and I2. RESULTS: A total of nine studies involving 7131 patients were included. A total of six factors were analyzed. Patients with older age (≥ 65 versus < 65), female sex (versus male), low body mass index (BMI) (< 25 versus ≥ 25 kg/m2), and poor bowel preparation (versus fair to good) had significantly longer CIT. The presence of diverticulosis and prior abdominal surgery were not significantly associated with prolonged CIT. CONCLUSIONS: The current meta-analyses have demonstrated that old age, female sex, low BMI, and poor bowel preparation were the predictors for prolonged CIT.

Nonalcoholic fatty liver disease and osteoporosis: a systematic review and meta-analysis.

Several major risk factors for osteoporosis have been identified. One of these risk factors is chronic inflammation. Several recent studies have supported the association between low bone mineral density (BMD) and nonalcoholic fatty liver disease (NAFLD), which comprises a spectrum of disorders involving liver inflammation. However, conflicting evidence regarding this association has been obtained thus far. We, therefore, conducted a meta-analysis of observational studies to show the association between NAFLD and BMD. The Cochrane Central Register of Controlled Trials, Cochrane Library, Medline, and Embase were searched from database inception to November 2014 for all observational studies evaluating the association between NAFLD or nonalcoholic steatohepatitis (NASH) and bone mass, BMD, or osteoporosis. All patients were ≥18 years of age and had no other cause of liver disease, osteoporosis, or pathological bone disease at baseline. Risk factors were NAFLD and NASH; control subjects were individuals without NAFLD. Eleven articles underwent full-length review. Data were extracted from five cross-sectional studies involving 1276 participants; 638 had NAFLD. The main meta-analysis showed no significant difference in BMD between patients with fatty liver disease and controls. Among all variables analyzed, body mass index had the strongest and most significant predictive effect on the difference in BMD. Controversy exists regarding the effect of BMD on NAFLD. Further studies are required to fully show this relationship.

Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis.

PURPOSE: Delayed post-polypectomy bleeding (PPB) is an infrequent but serious adverse event after colonoscopic polypectomy. Several studies have tried to identify risk factors for delayed PPB, with inconsistent results. This meta-analysis aims to identify significant risk factors for delayed PPB. METHODS: MEDLINE and EMBASE databases were searched through January 2016 for studies that investigated the risk factors for delayed PPB. Pooled odds ratio (OR) for categorical variables and mean differences (MD) for continuous variables and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity of effect size was quantified using the Q statistic and I 2. RESULTS: Twelve articles involving 14,313 patients were included. The pooled delayed PPB rate was 1.5% (95%CI, 0.7-3.4%), I 2 = 96%. Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant risk factors for delayed PPB, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not. CONCLUSIONS: Cardiovascular disease, hypertension, polyp size, and polyp location were associated with delayed PPB. More caution is needed when removing polyps in patients with these risk factors. Future studies are warranted to determine appropriate preventive hemostatic measures in these patients.

Association of Helicobacter pylori with Chronic Kidney Diseases: A Meta-Analysis.

BACKGROUND/OBJECTIVES: The reported risk of chronic kidney disease (CKD) in patients with Helicobacter pylori infection is conflicting. This meta-analysis was conducted to summarize all available data and to estimate the prevalence and association between H. pylori and kidney disease and CKD. METHODS: Comprehensive literature review was conducted using MEDLINE and EMBASE database through October 2016 to identify studies that reported the prevalence or the association between H. pylori infection and non-dialysis-dependent kidney diseases or CKD. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS: Of 4546 studies, nine cross-sectional studies met the eligibility criteria and were included in the meta-analysis. The estimated prevalence of H. pylori infection among subjects with kidney disease was 53% (95% CI 45-61%). The pooled OR of H. pylori in patients with non-dialysis-dependent kidney diseases was 1.20 (95% CI 0.73-1.97) when compared with the patients without kidney diseases. The meta-analysis was then limited to only studies evaluating the risk of H. pylori in CKD; the pooled OR of H. pylori in patients with CKD was 1.00 (95% CI 0.58-1.71). CONCLUSIONS: The estimated prevalence of H. pylori in patients with non-dialysis-dependent kidney diseases is 53%. This study does not support the association between H. pylori infection and non-dialysis-dependent kidney diseases nor CKD.

Association of Helicobacter pylori with the Risk of Hepatic Encephalopathy.

BACKGROUND/OBJECTIVES: Hepatic encephalopathy is the common manifestation of decompensated cirrhosis. The association between Helicobacter pylori (H. pylori) infection and hepatic encephalopathy has been shown in many epidemiologic studies. This meta-analysis was conducted to summarize all available studies to estimate the association between H. pylori infection and hepatic encephalopathy. METHODS: A comprehensive literature review was conducted using MEDLINE and EMBASE database through March 2017 to identify studies that reported the association between H. pylori infection and hepatic encephalopathy. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS: Of 15,233 studies, eleven studies (four cross-sectional, four case-control, and three cohort studies) met the eligibility criteria and were included in the meta-analysis. The pooled OR of hepatic encephalopathy in patients with H. pylori infection was 1.73 (95% CI 1.09-2.73) when compared with the patients without H. pylori infection. The association between H. pylori and hepatic encephalopathy was not statistically significant after the sensitivity analysis, excluding those using ELISA alone, with a pooled OR of 1.92 (95% CI 0.91-4.05, I 2 = 62%). There was no publication bias of overall included studies assessed by the funnel plots and Egger's regression asymmetry test. CONCLUSIONS: This study demonstrated a potential association between H. pylori infection and risk of hepatic encephalopathy. Future studies are required to assess the effect of chronicity of infection on the development of hepatic encephalopathy.

Testosterone, Sex Hormone-Binding Globulin and Nonalcoholic Fatty Liver Disease: a Systematic Review and Meta-Analysis.

INTRODUCTION AND AIM: Endogenous sex hormones are associated with the risk of diabetes and metabolic syndrome. Recent studies suggested the role of these hormones in nonalcoholic fatty liver disease (NAFLD). We conducted a systematic review and meta-analysis of observational studies investigating the association between sex hormones and NAFLD. MATERIAL AND METHODS: A comprehensive search of the databases of the MEDLINE and EMBASE was performed from inception through April 2016. The inclusion criterion was the observational studies that assessed the association of serum total testosterone (TT) and sex-hormone binding globulin (SHBG) and NAFLD. We calculated pooled effect estimates of TT and SHBG with 95% confidence intervals (CI) comparing between subjects with and without NAFLD by using random-effects model. RESULTS: Sixteen trials comprising 13,721 men and 5,840 women met the inclusion criteria. TT levels were lower in men with NAFLD (MD = -2.78 nmol/l, 95%CI -3.40 to -2.15, I2 = 99%) than in those without. Men with higher TT levels had lower odds of NAFLD whereas higher TT levels increased the odds of NAFLD in women. In both sexes, SHBG levels were lower in patients with NAFLD than controls and this inverse association was stronger in women than men and higher SHBG levels were associated with reduced odds of NAFLD. CONCLUSION: Our meta-analysis demonstrated a sex-dependent association between TT and NAFLD. Lower TT levels are associated with men with NAFLD and inversely associated with women with NAFLD, whereas higher SHBG levels are associated with lower NAFLD odds in both men and women.

Risk of colorectal adenomas, advanced adenomas and cancer in patients with colonic diverticular disease: Systematic review and meta-analysis.

BACKGROUND AND AIM: Diverticular disease and colorectal neoplasia are common digestive disorders worldwide. Both diseases share epidemiological trends and certain risk factors including advancing age, physical inactivity, and Western diet and lifestyle. Studies assessing the association between these diseases reported inconsistent results. Thus, we conducted a systematic review and meta-analysis to determine the association between diverticular disease and colorectal adenomas, advanced adenomas and cancer. METHODS: A comprehensive search of the databases MEDLINE and EMBASE was done from inception through March 2016. Inclusion criterion was the observational studies' assessment of the association between diverticular disease and colorectal neoplasia in adult participants. Pooled OR and 95% confidence interval (CI) were calculated using a random effect. RESULTS: Data were extracted from 14 observational studies (11 cross-sectional studies, one case-control study and two cohort studies). Diverticular disease was associated with increased odds of adenomas (OR = 1.67, 95% CI 1.27-2.21, 10 studies), but not associated with advanced adenomas (OR = 1.19, 95% CI 0.88-1.62, I2  = 52%, four studies) or colorectal cancer (OR = 1.36, 95% CI 0.47-3.92, I2  = 98%, seven studies). CONCLUSIONS: Our meta-analysis demonstrated that diverticular disease was associated with colorectal adenomas. Colonoscopists should be aware of this association and carefully examine the entire large bowel in individuals with diverticulosis.

Heparin-bridging therapy and risk of post-polypectomy bleeding: Meta-analysis of data reported by Japanese colonoscopists.

BACKGROUND AND AIM: Peri-procedural bridging (PPB) with heparin is recommended for patients with high thromboembolic risk who need to withhold antithrombotic therapy for colonoscopic polypectomy. However, little is known about the bleeding risk from heparin-bridging therapy itself. METHODS: MEDLINE and EMBASE databases were searched through January 2017 for studies that compared the risk of PPB in patients who received heparin-bridging therapy in lieu of antithrombotic agents for colonoscopic polypectomy and those who discontinued antithrombotic agents without receiving heparin. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model, generic inverse variance method. Between-study heterogeneity was quantified using the Q statistic and I2 . RESULTS: A total of five studies consisting of 2601 patients were identified. A significantly increased risk of PPB among bridged patients compared to non-bridged patients was demonstrated with a pooled OR of 8.29 (95% CI, 4.96-13.87). Statistical heterogeneity was low with I2 of 0%. CONCLUSION: The present study demonstrated a significantly increased risk of PPB among patients who underwent colonoscopic polypectomy and received heparin-bridging therapy in lieu of antithrombotic agents compared to patients who did not receive it.