Comparing EUS-directed Transgastric ERCP (EDGE) Versus Laparoscopic-Assisted ERCP Versus Enteroscopic ERCP: A Network Meta-analysis.

BACKGROUND: Management of choledocholithiasis in patients with Roux-en-Y gastric bypass surgery is challenging. This study aims to compare technical success rates, adverse events, and procedural time between 3 current approaches: endoscopic ultrasound-directed transgastric Endoscopic retrograde cholangiopancreatography (ERCP) (EDGE), enteroscopy-assisted ERCP (E-ERCP), and laparoscopic-assisted ERCP (LA-ERCP). METHODS: A systematic search of 5 databases was conducted. Direct and network meta-analyses were performed to compare interventions using the random effects model. A significance threshold of P < 0.05 was applied. RESULTS: Sixteen studies were included. On direct meta-analysis, technical success rates were comparable between EDGE and LA-ERCP (odds ratio: 0.768, CI: 0.196-3.006, P = 0.704, I2 = 14.13%). However, EDGE and LA-ERCP showed significantly higher success rates than E-ERCP. No significant differences in adverse events were found between EDGE versus LA-ERCP, EDGE versus E-ERCP, and LA-ERCP versus E-ERCP on direct meta-analysis. In terms of procedural time, EDGE was significantly shorter than E-ERCP [mean difference (MD): -31 minutes, 95% CI: -40.748 to -21.217, P < 0.001, I2 = 19.89%), and E-ERCP was shorter than LA-ERCP (MD: -44.567 minutes, 95% CI: -76.018 to -13.116, P = 0.005, I2 = 0%). EDGE also demonstrated a significant time advantage over LA-ERCP (MD: -78.145 minutes, 95% CI: -104.882 to -51.407, P < 0.001, I2 = 0%). All findings were consistent with network meta-analysis on random effects model. The heterogeneity of the model was low. CONCLUSIONS: EDGE and LA-ERCP showed superior technical success rates compared with E-ERCP. Adverse events did not significantly differ among the three approaches. Furthermore, EDGE demonstrated the shortest procedural duration. We recommend considering EDGE as a first-choice procedure.

Safety and Efficacy of Powered Non-Thermal Endoscopic Resection Device for Removal of Colonic Polyps: A Systematic Review and Meta-Analysis.

Background: Endoscopic mucosal resection is a frequently employed method for removing colonic polyps. Nonetheless, the recurrence of these polyps over a healed submucosal base can complicate the extraction of leftover lesions through standard procedures. EndoRotor®, a non-thermal device specifically designed for endoscopic mucosal resection, has recently been assessed for its utility in removing colonic polyps, non-dysplastic Barrett's esophagus, and pancreatic necrosis. We conducted a systematic review and meta-analysis to ascertain the safety and efficacy of EndoRotor® in resecting scared or recurrence colonic polyps. Methods: We conducted an exhaustive review of existing literature using databases such as Medline, Embase, Web of Science, and the Cochrane Library until January 2023. Our aim was to find all studies that assessed the safety of non-thermal endoscopic resection devices in removing colonic polyps. The primary outcome we focused on was the rate of technical success. Secondary outcomes that we considered included the frequency of remaining lesions and instances of adverse events. To analyze these data, we used comprehensive meta-analysis software. Results: Our analysis incorporated three studies comprising 54 patients who underwent resection of 60 lesions. The combined technical success rate was 93.9% (95% confidence interval (CI): 77.7-98.6%, I2 = 25.5%). In patients who had another endoscopic examination, 20 were found to have a residual lesion. After the initial session, the combined rate of remaining lesions was 39.8% (95% CI: 15.3-70.8%, I2 = 74.5%). There were eight occurrences of intraoperative bleeding and four instances of bleeding post-procedure. The combined rate of intraoperative bleeding was 13.2% (95% CI: 6.7-24.3%, I2 = 0%), and post-procedure bleeding stood at 8.5% (95% CI: 3.4-19.8%, I2 = 0%). Only one major bleeding event was recorded, and no cases of perforation were reported. Conclusion: Our research indicates that the EndoRotor® effectively removes scarred colonic polyps, though the rate of remaining lesions is significant, potentially necessitating several sessions for a thorough removal. There is a need for broader prospective studies, mainly randomized controlled trials, to further assess EndoRotor®'s efficiency and safety in eliminating colonic polyps.

Evaluating the diagnostic accuracy of magnetic resonance imaging in distinguishing strictures in Crohn's disease: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis sought to assess the diagnostic accuracy of magnetic resonance imaging (MRI) in distinguishing fibrotic from inflammatory strictures in Crohn's disease (CD) patients. METHODS: A rigorous and systematic exploration of five key databases yielded studies that met predefined criteria. Data were extracted for a comprehensive meta-analysis using MetaDiSC and MetaDTA software, providing diagnostic accuracy measures. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was utilized for evaluating the methodological quality and potential bias within the studies. RESULTS: The systematic review involved the evaluation of 7437 records, culminating in the inclusion of 22 studies. In detecting fibrotic strictures in CD patients, MRI exhibited a pooled sensitivity of 85.20% (95% CI: 76.10-91.20%) and specificity of 96.00% (95% CI: 87.80-98.70%). For differentiating fibrotic strictures from inflammatory stenosis, the sensitivity was 81.5% (95% CI: 70.2-89.20%), and the specificity was 97.2% (95% CI: 90.0-99.3%). In terms of assessing the severity of strictures, sensitivity stood at 90.4% (95% CI: 78.1-96.1%) and specificity at 89.4% (95% CI: 57.4-98.2%). The consistency of the diagnostic accuracy was observed across different geographical locations and the various reference tests applied in the studies. CONCLUSIONS: The results of this meta-analysis underscore the robust diagnostic accuracy of MRI in detecting fibrotic strictures, distinguishing between fibrotic and inflammatory strictures, and evaluating stricture severity in CD patients. These findings support the integration of MRI into standard diagnostic protocols for patients with CD. Further large-scale, multicenter trials are warranted to confirm these results and to identify any potential limitations associated with the application of MRI in this clinical setting.

Protein Induced by Vitamin K Absence or Antagonist-II Versus Alpha-Fetoprotein in the Diagnosis of Hepatocellular Carcinoma: A Systematic Review With Meta-Analysis.

Background: Protein induced by vitamin K absence or antagonist-II (PIVKA-II) and α-fetoprotein (AFP) are promising tumor markers for the diagnosis of hepatocellular carcinoma (HCC). Yet, their diagnostic performance differs throughout HCC investigations. The aim of this meta-analysis was to assess the effectiveness of PIVKA-II and AFP in the diagnosis of HCC. Methods: A systematic literature search was performed to identify relevant studies from eight databases, which were published up to February 2023, in order to compare the diagnostic performance of PIVKA-II and AFP for HCC. Pooled sensitivity and specificity were calculated. Summary receiver operating characteristic (SROC) curve was performed to assess the diagnostic accuracy of each biomarker. Results: Fifty-three studies were identified. The pooled sensitivity (95% confidence interval (CI)) of PIVKA-II and AFP was 0.71 (0.70 - 0.72) and 0.64 (0.63 - 0.65), respectively in diagnosis of HCC, and the corresponding pooled specificity (95% CI) was 0.90 (0.89 - 0.90) and 0.87 (0.87 - 0.88), respectively. The area under the ROC curve (AUC) of PIVKA-II and AFP was 0.89 (0.88 - 0.90) and 0.78 (0.77 - 0.79), respectively. Subgroup analysis demonstrated that PIVKA-II presented higher AUC values compared to AFP in terms of ethnic group (African, European, Asian, and American patients), etiology (mixed-type HCC, hepatitis C virus (HCV)-related, and hepatitis B virus (HBV)-related) and sample size of cases (≤ 100 and > 100). Conclusion: This study reveals that PIVKA-II is a promising biomarker for identifying and tracking HCC, exhibiting greater accuracy than AFP. Our findings indicate that PIVKA-II outperforms AFP in detecting HCC across diverse racial groups and sample sizes, as well as in cases of HBV-related, HCV-related, or mixed-etiology HCC.

Comparable Efficacy for Push Versus Pull Technique in Esophageal Food Impaction: Systematic Review with Meta-Analysis.

BACKGROUND: Esophageal food impaction (EFI) is a common GI emergency. Push and pull methods are used currently for EFI retrieval. We aim to review current available literature to compare success rates and evaluate adverse event rates of the two techniques. METHODS: A comprehensive literature search was performed using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO and Global Index Medicus. Odds ratio (OR) with 95% confidence interval (CI) was calculated when comparing the dichotomous variables. We aimed to evaluate technical success and adverse events for EFI comparing push and pull technique on single arm and comparator analysis. RESULTS: The search strategy yielded a total of 126 articles. 18 studies with 3528 participants were included. The technical success rate was 97.5% (CI 96.6-99.2%) in the push and 88.4% (CI 72.8-98.7%) in the pull technique with no statistical difference on comparator analysis. Overall rate of adverse events was 4.03% (CI 0.9-5.0%) in the push technique and 2.22% (CI 0-2.9%) in the pull technique with no statistical difference on comparator analysis (OR 95% CI 0.464-2.782, p = 0.78, I2 = 31.54%). There was no statistical difference between rate of lacerations and perforations either between the two techniques. CONCLUSION: Both techniques have acceptable clinical outcomes which appear within standard of care. Operator experience and individual clinical scenarios should guide decision-making regarding technique selection.

Comparing adalimumab and infliximab in the prevention of postoperative recurrence of Crohn's disease: a systematic review and meta-analysis.

Background: Crohn's disease is a relapsing disease that often requires operative management. Prevention of postoperative recurrence (POR) is critical to maintain remissions. Biologic agents have proven to be most successful in remission maintenance. We made a direct head-to-head comparison of the 2 anti-tumor necrosis factor agents, infliximab (IFX) and adalimumab (ADA), to compare endoscopic and clinical POR of Crohn's disease. Methods: We conducted a comprehensive literature search in 7 databases, including Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO, and Global Index Medicus. Odds ratios (OR) were calculated with 95% confidence intervals (CI) and P-values (<0.05 considered significant). We evaluated the total rates of endoscopic recurrence, endoscopic recurrence at 1 year, and clinical recurrence rates of IFX and ADA in a direct head-to-head comparison. Results: The search strategy yielded a total of 393 articles. Three studies with a total of 268 participants were included. Our meta-analysis showed no statistically significant difference in total endoscopic recurrence rate between ADA and IFX (27.1% vs. 32.3%, OR 0.696, 95%CI 0.403-1.201; P=0.193; I 2=0%). Nor was there any significant difference between the drugs in endoscopic recurrence rate at 1 year (OR 0.799, 95%CI 0.329-1.940; P=0.620) or clinical recurrence rate (OR 0.477, 95%CI 0.477-1.712; P=0.755). Conclusions: ADA and IFX show comparable efficacy in preventing POR endoscopically and clinically. The clinical decision should be based on cost, side-effects, tolerability, and patient preferences. Additional studies, particularly randomized controlled trials, are needed to determine generalizability.

Cap-Assisted Endoscopic Esophageal Foreign Body Removal Is Safe and Efficacious Compared to Conventional Methods.

INTRODUCTION: Esophageal foreign body impaction (FBI) is a commonly encountered gastrointestinal emergency requiring immediate intervention. Foreign bodies can be composed of food, commonly referred to as a "food bolus" (FB), or other matter (non-food). We aim to conduct systematic review and meta-analysis to compare cap-assisted and conventional endoscopic techniques for removal of esophageal FBI. METHODS: A comprehensive search technique was utilized to identify studies that used capped endoscopic devices to remove FB or other esophageal foreign bodies. The primary outcomes were the technical success rate, rate of en bloc retrieval, and procedure time. Secondary outcomes were overall adverse events, bleeding, mucosal tears, and perforation. RESULTS: Seven studies with a total of 1407 patients were included. The mean patient age was 55.3 (SD ± 7.2) years and 44.8% of patients were male. There were two RCTs and five observational studies among the included studies. The technical success rate was significantly higher in the cap-assisted group compared to the conventional group (OR 3.47, CI 1.68-7.168, I2 = 0%, p = < 0.001), as well as the en bloc retrieval rate (OR 26.90, CI 17.82-40.60, I2 = 0%, p = 0.001). There was a trend towards lower procedural time for the cap-assisted group compared to the conventional group, although the difference did not reach statistical significance (MD - 10.997, CI - 22.78-0.786, I2 = 99.9%, p = 0.06). The overall adverse events were significantly lower in the cap-assisted group compared to the conventional group (OR 0.118, CI 0.018-0.792, I2 = 81.79%, p = 0.02). CONCLUSION: The cap-assisted technique has improved efficacy and safety. To confirm these results, larger randomized trials are warranted.

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.

Impact of guidewire caliber on ERCP outcomes: Systematic review and meta-analysis comparing 0.025- and 0.035-inch guidewires.

Background and study aims The impact of guidewire caliber on endoscopic retrograde pancreatography (ERCP) outcomes are not clear. Recent studies have compared two guidewires, 0.035- and 0.025-inch, in randomized controlled trials (RCTs). We performed a systematic review and meta-analysis of available RCTs to assess if different caliber would change the outcomes in ERCP. Patients and methods A systematic search of PubMed/Medline, Embase, Cochrane, SciELO, Global Index Medicus and Web of Science was undertaken through November 23, 2021 to identify relevant RCTs comparing the two guidewires. Binary variables were compared using random effects model and DerSimonian-Laird approach. For each outcome, risk-ratio (RR), 95 % confidence interval (CI), and P values were generated. P  < 0.05 was considered significant. Results Three RCTs with 1079 patients (556 in the 0.035-inch group and 523 in the 0.025-inch group) were included. The primary biliary cannulation was similar in both groups (RR: 1.02, CI: 0.96-1.08, P  = 0.60). The overall rates of PEP were also similar between the two groups (RR: 1.15, CI: 0.73-1.81, P  = 0.56). Other outcomes (overall cannulation rate, cholangitis, perforation, bleeding, use of adjunct techniques) were also comparable. Conclusions The results of our analysis did not demonstrate a clear benefit of using one guidewire over other. The endoscopist should consider using the guidewire based on his technical skills and convenience.

Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: Systematic review and meta-analysis.

Background and study aims Esophageal defects (leaks, fistulas, and perforations) are associated with significant morbidity and mortality. Endoluminal vacuum-assisted closure (EVAC) is a novel intervention that entails the use of sponges in the defect along with negative pressure to achieve granulation tissue formation and healing and has been gaining popularity. We performed a systematic review and pooled analysis of available literature to assess the safety and effectiveness of EVAC for esophageal defects. Patients and methods We queried PubMed/Medline, Embase, Cochrane, and Web of Science through September 25, 2020 to include all pertinent articles highlighting the safety and effectiveness profile of EVAC for esophageal defects. Pooled rates, 95 % confidence intervals (CIs), and heterogeneity ( I 2 ) were assessed for each outcome. Results A total of 18 studies with 423 patients were included (mean age 64.3 years and males 74.4 %). The technical success for EVAC was 97.1 % (CI: 95.4 %-98.7 %, I 2  = 0 %). The clinical success was 89.4 % (CI: 85.6 %-93.1 %, I 2  = 36.8 %). The overall all-cause mortality and adverse events (AEs) noted were 7.1 % (CI: 4.7 %-9.5 %, I 2  = 0 %) and 13.6 % (CI: 8.0 %-19.1 %, I 2  = 68.9 %), respectively. The pooled need for adjuvant therapy was 15.7 % (CI: 9.8 %-21.6 %, I 2  = 71.1 %). Conclusions This systematic review and meta-analysis showed high rates of technical success, clinical success, and low all-cause mortality and AEs using EVAC. Although the technique is a promising alternative, the lack of comparative studies poses a challenge in making definite conclusions regarding use of EVAC compared to other endoscopic modalities, such as clips and stents.

The association between obstructive sleep apnea and non-alcoholic steatohepatitis: a retrospective nationwide inpatient sample analysis.

AIM OF THE STUDY: The primary purpose of this study was to assess the association of obstructive sleep apnea (OSA) and non-alcoholic steatohepatitis (NASH) from a large national inpatient sample database. MATERIAL AND METHODS: We conducted a retrospective analysis using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. OSA and NASH patients were identified using the ICD-10-CM code G47.33 and K75.81. Non-NASH patients (control) were randomly selected and matched by age and gender to each NASH patient in a 4 : 1 ratio. Weighted logistic regression models were used to calculate the association between OSA and NASH in addition to different comorbidities. RESULTS: A total of 54,169 participants were included in our analysis; 10,740 cases of NASH were matched to 43,429 controls (non-NASH). NASH was significantly higher in the white population (82.12% vs. 76.64%, p < 0.001). The prevalence of OSA among NASH patients was significantly higher compared to the control group (15.8% vs. 8.9%, adjusted OR: 1.34, 95% CI: 1.14-1.56, p = 0.0003). The prevalence of celiac disease and Crohn's disease was significantly higher in patients with NASH (0.7% vs. 0.2%, p < 0.0002 and 1.28% vs. 0.76%, p < 0.0001). Multiple comorbidities were significantly elevated in the NASH group compared to the non-NASH group, including diabetes mellitus (DM; 36% vs. 17.6%, p < 0.0001), obesity (36.4% vs. 18.2%, p < 0.0001) and metabolic syndrome (0.86% vs. 0.06%, p < 0.0001). The mortality rate was significantly higher in the NASH group (3.8% vs. 2%, p < 0.0001). CONCLUSIONS: This is the first study using the ICD-10-CM code with a specific search code for NASH. Our large population database results emphasize that there is a significant association between OSA and NASH.

Antireflux valve metal stent versus conventional self-expandable metal stent in distal malignant biliary obstruction: a systematic review and meta-analysis.

BACKGROUND: In patients with distal malignant biliary obstruction (MBO), endoscopic biliary drainage using the conventional self-expandable metal stent (SEMS) is the gold standard method for palliative treatment. However, there are limited data on the role of the antireflux valve metal stent (ARVMS). The aim of this study was to compare the safety and efficacy of ARVMS and SEMS in patients with distal MBO. METHODS: We searched PubMed, Ovid, Embase and the Cochrane Library from inception until April 2019 for relevant randomized controlled trials (RCTs). The selected studies provided data regarding technical and clinical success rates, adverse events, and stent dysfunction. Data were meta-analyzed using RevMan software. RESULTS: Three RCTs were selected, enrolling 293 patients (147 ARVMS and 146 SEMS). The rates of technical success were 95.23% and 99.31% for ARVMS and SEMS groups, respectively (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.01-1.06; P=0.06). The clinical success rates were 91.57% and 89.36% for ARVMS and SEMS groups, respectively (OR 1.30, 95%CI 0.48-3.51; P=0.61). There was no significant difference between the ARVMS and SEMS groups in terms of adverse events (OR 0.61, 95%CI 0.35-1.05; P=0.07) or stent dysfunction (OR 0.77, 95%CI 0.31-1.95; P=0.58), while the incidence of stent occlusion was significantly lower in the ARVMS group (OR 0.44, 95%CI 0.26-0.76; P=0.003). CONCLUSION: Our study showed that ARVMS and SEMS had similar technical and clinical success rates. Adverse events were comparable between the 2 arms; however, ARVMS was associated with a lower risk of stent occlusion. Larger RCTs are required to verify the benefit of ARVMS in distal MBO patients.

On-Demand Therapy with Proton Pump Inhibitors for Maintenance Treatment of Nonerosive Reflux Disease or Mild Erosive Esophagitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Proton pump inhibitors (PPIs) are widely used for the long-term management of gastroesophageal reflux disease (GERD). However, concerns about the cost and/or inconvenience of continuous maintenance PPI treatment have led to the evaluation of various alternative approaches. AIM: To assess the effectiveness of on-demand PPI therapy in the maintenance treatment of nonerosive reflux disease (NERD) or mild erosive esophagitis (EE). METHODS: We searched MEDLINE, EMBASE, Web of Science, and Cochrane Library from inception until October 2, 2017, for randomized controlled trials (RCTs) comparing on-demand PPI versus placebo or daily PPI in the management of NERD or mild EE (Savary-Miller grade 1). Discontinuation of therapy during the trial was used as a surrogate for patient dissatisfaction and failure of symptomatic control. We calculated pooled odds ratios (OR) to evaluate the efficacy of on-demand PPI treatment. Separate analyses were conducted for studies comparing on-demand PPI with daily PPI and with placebo. Subgroup analysis was done based on NERD studies alone and on studies of both NERD and mild EE. These were analyzed using a random effects model. RESULTS: We included 10 RCTs with 4574 patients. On-demand PPI was superior to daily PPI (pooled OR = 0.50; 95% confidence interval (CI) = 0.35, 0.72). On subgroup analysis in NERD patients only, pooled OR was 0.44 (0.29, 0.66). In studies including patients with NERD and mild EE, pooled OR was 0.76 (0.36, 1.60). For studies comparing on-demand PPI with placebo, pooled OR was 0.21 (0.15, 0.29); subgroup analyses of studies evaluating NERD only and studies conducted in NERD and mild EE showed similar results (pooled OR was 0.22 (0.13, 0.36) and 0.18 (0.11, 0.31), resp.). CONCLUSIONS: On-demand PPI treatment is effective for many patients with NERD or mild EE. Although not FDA-approved, it may be adequate for those patients whose symptoms are controlled to their satisfaction.

Ectopic Pancreas in the Gastric Antrum Wall Complicated by Ectopic Pancreatitis and Persistent Gastric Abscess.

Ectopic pancreas is an uncommon finding in the stomach. Complications are rare but can lead to significant morbidity and even mortality. We report a 49-year-old man who presented with upper abdominal pain, vomiting, and weight loss and was found to have a gastric wall abscess that developed a few weeks after endoscopic biopsy of a gastric ulcer. After medical treatment failed to resolve his symptoms, he underwent distal gastrectomy with Roux-en-Y gastrojejunostomy. Postoperatively, the gastric wall abscess was determined to have derived from a focus of ectopic pancreatic tissue with evidence of ectopic chronic pancreatitis.

Improving Internal Medicine Residents' Colorectal Cancer Screening Knowledge Using a Smartphone App: Pilot Study.

BACKGROUND: Colorectal cancer (CRC) is the third most common type of cancer and the second leading cause of cancer death in the United States. About one in three adults in the United States is not getting the CRC screening as recommended. Internal medicine residents are deficient in CRC screening knowledge. OBJECTIVE: The objective of our study was to assess the improvement in internal medicine residents' CRC screening knowledge via a pilot approach using a smartphone app. METHODS: We designed a questionnaire based on the CRC screening guidelines of the American Cancer Society, American College of Gastroenterology, and US Preventive Services Task Force. We emailed the questionnaire via a SurveyMonkey link to all the residents of an internal medicine department to assess their knowledge of CRC screening guidelines. Then we designed an educational intervention in the form of a smartphone app containing all the knowledge about the CRC screening guidelines. The residents were introduced to the app and asked to download it onto their smartphones. We repeated the survey to test for changes in the residents' knowledge after publication of the smartphone app and compared the responses with the previous survey. We applied the Pearson chi-square test and the Fisher exact test to look for statistical significance. RESULTS: A total of 50 residents completed the first survey and 41 completed the second survey after publication of the app. Areas of CRC screening that showed statistically significant improvement (P<.05) were age at which CRC screening was started in African Americans, preventive tests being ordered first, identification of CRC screening tests, identification of preventive and detection methods, following up positive tests with colonoscopy, follow-up after colonoscopy findings, and CRC surveillance in diseases. CONCLUSIONS: In this modern era of smartphones and gadgets, developing a smartphone-based app or educational tool is a novel idea and can help improve residents' knowledge about CRC screening.

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome). METHODS: We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with ≥ 10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model. RESULTS: Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I 2 = 15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I 2 = 50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P = 0.51). WPR for AE was 13% (9, 20%), (I 2 = 64%). AE were 10% more in WON as compared to PP (P = 0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I 2 = 50%). Pooled MD for number of endoscopic sessions was - 0.84 (- 1.69, 0.01). CONCLUSIONS: LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

Viral Hepatitis in South Korea.

In South Korea (S. Korea), viral hepatitis is a major public health burden. Advances in healthcare policy, evidence-based medicine, and therapeutic strategies in S. Korea have brought a rapid change in the sociodemographic and clinical characteristics of viral hepatitis. This review discusses the innovative approaches that S. Korea has taken to curb the epidemic of viral hepatitis. In addition, the efficacy of various preventive and therapeutic modalities is discussed. This review aims to provide a brief overview to guide future research direction and healthcare policy changes. How to cite this article: Pak SC, Alastal Y, Khan Z, Darr U. Viral Hepatitis in South Korea. Euroasian J Hepato-Gastroenterol 2017;7(2):163-165.

Long Esophageal Stricture in a Brittle Diabetic.

AIM: We report a case of atypical esophageal stricture in a young diabetic woman. BACKGROUND: Diabetes mellitus and gastroesophageal reflux disease (GERD) are two common disorders in modern society. CASE REPORT: A young diabetic woman developed a 6-cm-long esophageal stricture. This stricture was refractory to multiple esophageal dilation procedures. She underwent subtotal esophagectomy and had excellent treatment outcome. CONCLUSION: Gastroesophageal reflux disease can cause severe long esophageal stricture in a brittle diabetic. CLINICAL SIGNIFICANCE: Improving the awareness of their association between diabetes and GERD would greatly benefit the day-to-day practice of medicine.How to cite this article: Pak SC, Darr U, Alastal Y, Yoon Y. Long Esophageal Stricture in a Brittle Diabetic. Euroasian J Hepato-Gastroenterol 2017;7(2):191-192.

The Traumatic Tube: Bleeding Rectal Ulcer Caused by Flexi-Seal Device.

Diarrhea and fecal incontinence are common in critically ill patients and present a challenging problem in patient management. The Flexi-Seal® Fecal Management System is a device to divert the stools away from the patient, thus improving the care to patients with fecal incontinence. There have been only few case reports describing the complications with the use of this device. Here, we present a case of a 77-year-old woman who was admitted due to massive hematochezia while on anticoagulation. She was found to have a large rectal ulcer caused by the Flexi-Seal device, used during the last hospital stay for fecal incontinence. Flexi-Seal device can be effective for the management of incontinence; however, caution should be exercised during handling and pressure from the retention balloon should be relieved periodically.

Gastrointestinal manifestations associated with systemic sclerosis: results from the nationwide inpatient sample.

BACKGROUND: Systemic sclerosis (SSc) is a multisystem disease associated with significant morbidity and increased mortality. The prevalence of different gastrointestinal (GI) manifestations has been investigated in multiple, but mainly small, retrospective studies. In this study, we investigated the prevalence and risk for a broad spectrum of GI disorders and malignancies in a large sample of inpatients with SSc in the United States. METHODS: We conducted a retrospective analysis using the 2010-2011 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS). SSc patients were identified by ICD-9-CM code 710.1. Non-SSc patients ("controls") were matched to cases 4:1 by age and sex. We examined demographics, clinical characteristics, and a range of GI conditions. RESULTS: From 15,824,031 total patients, 13,633 cases of SSc were matched to 54,532 controls. The prevalence of GI manifestations among SSc patients was 59.24% compared to 29.96% for controls (P<0.0001). Significantly elevated GI manifestations in SSc patients included dysphagia (4.3% vs. 1.9%, P<0.0001), esophageal reflux (34.8% vs. 15.4%, P<0.0001), Barrett's esophagus (1.7% vs. 0.3%, P<0.0001), constipation (6% vs. 4.6%, P<0.0001), diarrhea (4.5% vs. 2.4%, P<0.0001), fecal incontinence (0.4% vs. 0.2%, P<0.0001), and celiac disease (0.2% vs. 0%, P<0.0001). Some GI disorders were significantly lower in SSc patients, including cholelithiasis (1.6% vs. 2.1%, P<0.0001) and GI malignancies (1% vs. 2.2%, P<0.0001). CONCLUSIONS: Our results emphasize the established association between SSc and esophageal disorders, such as dysphagia and reflux disease. Our analysis indicated a significant positive association between SSc and celiac disease, and a negative association between SSC and cholelithiasis.