Endoscopic submucosal dissection vs. endoscopic mucosal resection in the treatment of early Barrett's neoplasia: Systematic review and meta-analysis.

OBJECTIVES: Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia. METHODS: An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence. RESULTS: A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04). CONCLUSION: Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.

Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis.

Background: Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length. Objective: The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD. Methods: All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity). Results: There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]). Conclusions: The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.

Effectiveness and Safety of the Allurion Swallowable Intragastric Balloon for Short-term Weight Loss: A Systematic Review and Meta-analysis.

BACKGROUND: Obesity poses a severe health problem worldwide, with an estimated impact on 17.5% of the adult population by 2035. Among the endoscopic applications for treating this comorbidity, intragastric balloons are the most widely used. The new liquid-filled swallowable balloon meets the requirements of major guidelines and allows significant weight loss with few adverse events. This systematic review and meta-analysis aims to demonstrate the efficacy and safety profile of this new device for weight loss. METHODS: We conducted a search from 2016 to 2024 to assess the efficacy of the swallowable intragastric balloon for weight loss, including improvements in metabolic profiles and anthropometric measurements. Additionally, we evaluated potential adverse events related to the device to demonstrate its safety. RESULTS: Eleven observational studies totalling 2107 patients were included, showing a reduction of 4.75 in BMI (95% CI: -5.02; -4.47), a mean total weight loss of 12.47% (95% CI: -13.77; -11.17), a mean excess weight loss of 48.04% (95% CI: -50.61; -45.48), and a rate of serious adverse events of 0.90%. An improvement in the metabolic profile was observed for three parameters: HDL, triglycerides, and glycaemia. CONCLUSION: The swallowable liquid-filled intragastric balloon is safe and effective for managing weight loss within a four-month follow-up period.

Invasive Therapeutic Strategies for Stricturing Crohn's Disease in Childhood: A Systematic Review and Meta-Analysis.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. Current drugs are not effective for treating the primary fibrotic component of CD. Recommended invasive treatments include endoscopic balloon dilation, surgery with resection, or strictureplasty. This meta-analysis compared invasive treatment techniques for CD-related strictures in the pediatric population. METHODS: The MEDLINE, EMBASE, and LILACS databases were searched from inception to December 2023. This meta-analysis was performed as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome was measured by the rate of stenosis recurrence and the adverse events of the techniques. Eligibility criteria were studies that involved the analysis of the recurrence rate of stenosis in pediatric patients with CD requiring surgical intervention after undergoing any of the previously proposed therapies. Additionally, adverse events were analyzed. RESULTS: Three studies comprising a total of 106 endoscopic balloon dilations demonstrated a combined rate of stricture recurrence in patients with CD requiring surgical intervention of 0.171 (95% confidence interval [CI], 0.110-0.255). Three studies comprising a total of 49 surgical resections demonstrated a pooled event rate of 0.100 (95% CI, 0.038-0.240). Finally, 2 studies comprising a total of 38 strictureplasties demonstrated a pooled event rate of 0.347 (95% CI, 0.070-0.789). Concerning adverse events, the most common occurrences were found after surgical resection. CONCLUSIONS: Surgical resection is the best option for treating strictures in pediatric CD patients in terms of recurrence rate, compared with endoscopic balloon dilation and strictureplasty. Nevertheless, surgical resection is associated with more adverse events.

This meta-analysis compares techniques for pediatric Crohn's disease­related strictures. Surgical resection, compared with balloon dilation or strictureplasty, is the best option for treating strictures in these patients in terms of recurrence rate but is associated with more adverse events.

Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis.

Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.

Impact of Endoscopic Sleeve Gastroplasty in Non-alcoholic Fatty Liver Disease: a Systematic Review and Meta-analysis.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. Endoscopic sleeve gastroplasty (ESG) has proven to be feasible, safe, and effective in the management of obesity. We performed the first systematic review and meta-analysis evaluating NAFLD and other metabolic parameters 12 months post-ESG. Four observational studies with a total of 175 patients were included. The results showed a significant (p < 0.05) reduction of 4.85 in hepatic steatosis index (95% CI - 6.02, - 3.67), 0.5 in NAFLD fibrosis score (95% CI - 0.80, - 0.19), 6.32 U/l in ALT (95% CI - 9.52, - 3.11), 17.28% in TWL (95% CI - 18.24, - 16.31), 6.31 kg/m2 in BMI (95% CI - 8.11, - 4.52), 47.97% in EWL (95% CI - 49.10, - 46.84), and 0.51% in HbA1c (95% CI - 0.90, - 0.12). ESG improves liver parameters, provides weight loss, and reduces HbA1c levels in patients suffering from NAFLD.

Pseudotumoral Amyloidosis Presentation With Upper Digestive Bleeding.

Amyloidosis is a condition related to the extracellular deposition of abnormal fibrillar proteins. Gastric involvement may present as a systemic or localized form of the disease. The endoscopic presentation can vary from nodular, ulcerated, or infiltrative lesions. Clinical manifestations are nonspecific, including hyporexia, nausea, vomiting, weight loss, epigastralgia, and abdominal discomfort. Thus, amyloidosis can clinically and endoscopically mimic other diseases, such as neoplasms, syphilis, tuberculosis, and Crohn's disease, requiring a high suspicion. When it manifests with gastrointestinal bleeding, it most commonly occurs as intermittent melena. This report aims to present an unusual case of a patient with upper gastrointestinal bleeding exteriorized through melena secondary to amyloidosis with gastric involvement.

Endoscopic Imaging for the Diagnosis of Neoplastic and Pre-Neoplastic Conditions of the Stomach.

Gastric cancer is an aggressive disease with low long-term survival rates. An early diagnosis is essential to offer a better prognosis and curative treatment. Upper gastrointestinal endoscopy is the main tool for the screening and diagnosis of patients with gastric pre-neoplastic conditions and early lesions. Image-enhanced techniques such as conventional chromoendoscopy, virtual chromoendoscopy, magnifying imaging, and artificial intelligence improve the diagnosis and the characterization of early neoplastic lesions. In this review, we provide a summary of the currently available recommendations for the screening, surveillance, and diagnosis of gastric cancer, focusing on novel endoscopy imaging technologies.

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) and Heller myotomy with fundoplication (HMF) effectively treat achalasia, an esophageal motor disease. Although a significant number of meta-analyses have compared POEM and HMF, these studies showed discrepant postoperative gastroesophageal reflux disease (GERD) conclusions. This review aimed to objectively compare GERD over time, as well as the efficiency, safety, and adverse events in POEM versus HMF for treating achalasia. We performed a systematic review and meta-analysis by searching Medline, Embase, Cochrane Library, Scopus, and Clinicaltrials.gov. The evaluated outcomes included early (within 12 months) and late (beyond 12 months) endoscopic assessment of GERD using the Lyon Consensus, clinical success, operative duration (OD), length of stay (LOS), and major adverse events (MAE). A total of 29 observational studies and two randomized clinical trials (RCTs) with 13,914 patients were included. GERD was 28% higher among RCTs discussing POEM at early assessment (95%CI 0.02, 0.54) and was not different at late evaluation (95% confidence interval (CI) = 0.00, 0.22). No difference in reflux was observed among observational studies in both periods. The clinical success was 9% higher (95% CI = 0.05, 0.12), and the OD was 37.74 minutes shorter (95% CI = -55.44, -20.04) in POEM among observational studies, whereas it was not different among RCTs. The LOS and MAE were similar in the groups. Comparisons among studies yielded divergent results. RCTs revealed that POEM had a higher incidence of GERD in the early assessment, whereas observational studies showed higher clinical success and a shorter OD in POEM. Ultimately, the between-group difference waned over time in GERD in all comparisons, resulting in no difference among RCTs in the late evaluation. Our meta-analysis demonstrated a non-preferential treatment of achalasia between endoscopic or surgical cardiomyotomy, prioritizing an individualized approach in the long term.

Anti-reflux versus conventional self-expanding metal stents in the palliation of esophageal cancer: A systematic review and meta-analysis.

Background and study aims Self-expanding metal stents (SEMS) are an effective palliative endoscopic therapy to reduce dysphagia in esophageal cancer. Gastroesophageal reflux disease (GERD) is a relatively common complaint after non-valved conventional SEMS placement. Therefore, valved self-expanding metal stents (SEMS-V) were designed to reduce the rate of GERD symptoms. We aimed to perform a systematic review and meta-analysis comparing the two stents. Material and methods This was a systematic review and meta-analysis including only randomized clinical trials (RCT) comparing the outcomes between SEMS-V and non-valved self-expanding metal stents (SEMS-NV) following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Data were analyzed with Review Manager Software. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation guidelines. Results Ten randomized clinical trials including a total of 467 patients, 234 in the SEMS-V group and 233 in the SEMS-NV group, were included. There were no statistically significant differences regarding GERD qualitative analysis (RD -0.17; 95 % CI -0.67, 0.33; P  = 0.5) and quantitative analysis (SMD -0.22; 95 % CI -0.53, 0.08; P  = 0.15) technical success (RD -0.03; 95 % CI -0.07, 0.01; P  = 0.16), dysphagia improvement (RD -0.07; 95 % CI -0.19, 0.06; P  = 0.30), and adverse events (RD 0.07; 95 % CI -0.07, 0.20; P  = 0.32). Conclusions Both SEMS-V and SEMS-NV are safe and effective in the palliation of esophageal cancer with similar rates of GERD, dysphagia relief, technical success, adverse events, stent migration, stent obstruction, bleeding, and improvement of the quality of life.

Endoscopic Resection Versus Surgery in the Treatment of Early Gastric Cancer: A Systematic Review and Meta-Analysis.

Background and Aim: Endoscopic resection (ER) is the preferred approach to treat early gastric cancer (EGC) in patients without suspected lymph node involvement and that meet the criteria for ER. Surgery is a more aggressive treatment, but it may be associated with less recurrence and the need for reintervention. Previous meta-analyses comparing ER with surgery for EGC did not incorporate the most recent studies, making accurate conclusions not possible. Methods: This systematic review and meta-analysis aimed to examine complete resection, length of hospital stay (LOHS), adverse events (AEs), serious AEs, recurrence, 5-year overall survival (OS), and 5-year cancer-specific survival (CSS) in patients with EGC. Results: A total of 29 cohorts studies involving 20559 patients were included. The ER (n = 7709) group was associated with a lower incidence of AEs (RD = -0.07, 95%CI = -0.1, -0.04, p < 0.0001) and shorter LOHS (95% CI -5.89, -5.32; p < 0,00001) compared to surgery (n = 12850). However, ER was associated with lower complete resection rates (RD = -0.1, 95%CI = -0.15, -0.06; p < 0.00001) and higher rates of recurrence (RD = 0.07, 95%CI = 0.06; p < 0.00001). There were no significant differences between surgery and ER in 5-year OS (RD = -0.01, 95%CI = -0.04, 0.02; p = 0.38), 5-year CSS (RD = 0.01, 95%CI = 0.00, 0.02; p < 0.17), and incidence of serious AEs (RD = -0.03, 95%CI = -0.08, 0.01; p = 0.13). Conclusions: ER and surgery are safe and effective treatments for EGC. ER provides lower rates of AEs and shorter LOHS compared to surgery. Although ER is associated with lower complete resection rates and a higher risk of recurrence, the OS and CSS were similar between both approaches. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021255328.