Histological Outcomes of Pharmacological Interventions in Eosinophilic Esophagitis for Adults and Children: A Network Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Multiple pharmacological interventions have been studied for managing eosinophilic esophagitis (EoE). We performed a comprehensive systematic review and network meta-analysis of all available randomized controlled trials (RCT) to assess the efficacy and safety of these interventions in EoE in adults and children. METHODS: We performed a comprehensive review of Embase, PubMed, MEDLINE OVID, Cochrane CENTRAL, and Web of Science through May 10, 2023. We performed frequentist approach network meta-analysis using random effects model. We calculated the odds ratio (OR) with 95% CI for dichotomous outcomes. RESULTS: Our search yielded 25 RCTs with 25 discrete interventions and 2067 patients. Compared with placebo, the following interventions improved histology (using study definitions) in decreasing order on ranking: orodispersible budesonide (ODB) low dose, ODB high dose, oral viscous budesonide (OVB) high dose, fluticasone tablet 1.5 mg twice daily, fluticasone 3 mg twice daily, esomeprazole, dupilumab every 2 weeks, dupilumab weekly, OVB medium dose, fluticasone 3 mg daily, cendakimab 180 mg, prednisone, swallowed fluticasone, fluticasone tablet 1.5 mg daily, OVB low dose, reslizumab 3 mg/kg, reslizumab 1 mg/kg, and reslizumab 2 mg/kg. CONCLUSIONS: Network meta-analysis demonstrates histological efficacy of multiple medications for EoE. Because of the heterogeneity and large effect size, we recommend more trials comparing pharmacotherapeutic interventions with each other and placebo. An important limitation of this study is absence of clinical efficacy data due to insufficient data. Other limitations include heterogeneity of operator, population, and outcome analysis.

Sarcopenia is a risk factor for post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy and mortality: A systematic review and meta-analysis.

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly performed procedure in patients with liver cirrhosis to treat portal hypertension-related conditions, including variceal bleeding and refractory ascites. However, while the increased risk of hepatic encephalopathy (HE) after TIPS is important to consider when determining whether a patient is a good candidate for TIPS, currently there is no widely used method to predict the development of post-TIPS HE, although the model for end-stage liver disease (MELD) score is used to predict post-TIPS mortality. We conducted a systematic review and meta-analysis to evaluate sarcopenia as a risk factor for HE and mortality in patients undergoing TIPS. METHODS: A comprehensive search strategy was used to identify reports of post-TIPS HE and mortality in sarcopenia vs. non-sarcopenia patients with liver cirrhosis who received TIPS in March 2023. Open Meta Analyst was used to compute the results. RESULTS: Twelve studies with 2056 patients met inclusion criteria and were included in the final meta-analysis. Sarcopenia was associated with a significantly higher post-TIPS HE rate than non-sarcopenia (risk ratio [RR]: 1.68, 95% CI: 1.48-1.92, p < 0.00001, I2 = 65%), as well as a significantly higher post-TIPS mortality rate (RR: 1.73, 95% CI: 1.14-2.64, p < 0.00001, I2 = 87%). CONCLUSION: Patients with sarcopenia have a significantly increased risk of post-TIPS HE and mortality. Presence of sarcopenia should be considered when weighing the risks and benefits of performing TIPS in patients with cirrhosis. Further studies are needed to determine the clinical utility of important risk factors such as sarcopenia on post-TIPS outcomes.

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.

Trends of Upper Gastrointestinal Bleeding Mortality in the United States Before and During the COVID-19 Era: Estimates From the Centers for Disease Control WONDER Database.

Background: There have been reports of increased upper gastrointestinal bleeding (UGIB) in patients with coronavirus disease 2019 (COVID-19). Still, only a few studies have examined the mortality rate associated with UGIB in the United States before and during COVID-19. Hereby, we explored the trends of UGIB mortality in the United States before and during COVID-19. The study's objective was to investigate whether the COVID-19 pandemic significantly impacted UGIB mortality rates in the USA. Methods: The decedents with UGIB were included. Age-standardized mortality rates were estimated with the indirect method using the 2000 US Census as the standard population. We utilized the deidentified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Linear regression analysis was performed to determine 2021 projected mortality rates based on trends between 2012 and 2019 to quantify the association of the pandemic with UGIB-related deaths. Results: The mortality rate increased from 3.3 per 100,000 to 4.3 per 100,000 among the population between 2012 and 2021. There was a significant increase in the overall mortality rate between each year and the following year from 2012 to 2019, ranging from 0.1 to 0.2 per 100,000, while the rise in the overall mortality rate between each year and 2021 ranges from 0.4 to 0.9 per 100,000. Conclusions: Our results showed that the mortality rate increased among the population between 2012and 2021, suggesting a possible influence of COVID-19 infection on the incidence and mortality of UGIB.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis.

Background: Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes. Methods: Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software. Results: The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I2 = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG. Conclusion: PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

Comparative Efficacy of Treatment Options for the Prevention of Post-TIPS Hepatic Encephalopathy: A Systematic Review and Network Meta-analysis.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is often used in patients with cirrhosis to manage portal hypertension-related complications. Unfortunately, 35-50% of patients develop overt hepatic encephalopathy (HE) after TIPS. However, data on lactulose and rifaximin to prevent post-TIPS HE is limited. Therefore, we aimed to perform a network meta-analysis to investigate the efficacy of multiple pharmacological regimens in the prevention of post-TIPS HE. METHODS: A comprehensive search strategy to identify reports of studies of rifaximin use on post-TIPS hepatic encephalopathy was constructed using truncated keywords, phrases, and subject headings developed in Embase. This strategy was translated to MEDLINE, Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection, with all searches performed on 10 February 2022. No publication date or language limits were used. RESULTS: The initial search identified 72 studies, and 56 studies were screened after removing duplicates. Five studies, two randomized controlled trials (RCTs) and three retrospective studies, met our inclusion criteria and were included in the final analysis. A total of 840 patients were included, with 65% male. Our meta- analysis did not find a statistically significant difference between lactulose vs placebo/no prophylaxis, nor rifaximin vs placebo/no prophylaxis, nor rifaximin plus lactulose vs placebo/no prophylaxis in the reduction of post-TIPS HE. CONCLUSIONS: Rifaximin alone, lactulose alone, and rifaximin plus lactulose did not significantly reduce the development of post-TIPS HE. Based on the P-scores of the three treatment groups, the combination of rifaximin plus lactulose showed the most promising trend towards preventing post-TIPS HE. More studies, especially large RCTs, are warranted.

Fresh Versus Frozen Versus Lyophilized Fecal Microbiota Transplant for Recurrent Clostridium Difficile Infection: A Systematic Review and Network Meta-analysis.

INTRODUCTION: Clostridium difficile Infection is a significant source of morbidity and mortality, which is on the rise. Fecal Microbiota Transplantation (FMT) is an alternative therapy to antibiotics with a high success rate and low relapse rate. Current data regarding the efficacy of the types of FMT used, namely fresh, frozen, and lyophilized is conflicting. Our review attempts to consolidate this data and highlight the most efficacious treatment currently available. METHODOLOGY: MEDLINE, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, SciELO, the Korean Citation Index, and Global Index Medicus were systematically searched from inception through May 3, 2022. Studies in which patients are undergoing any form of FMT who had failed antibiotic treatment previously were included. Both pairwise (direct) and network (direct + indirect) meta-analysis were performed using a random effects model and DerSimonian-Laird approach. A frequentist approach was used for network meta-analysis. Risk differences with (RD) with 95% confidence interval (CI) were calculated. RESULTS: A total of 8 studies, including 4 RCTs and 4 cohort studies, were included with a total of 616 patients. Fresh FMT was determined to be most successful with 93% efficacy 95% CI (0.913 to 0.999) followed by frozen with 88% efficacy 95% CI (0.857 to 0.947) and lyophilized with 83% efficacy 95% CI (0.745 to 0.910). The direct meta-analysis showed no statistically significant difference between fresh and frozen group. (RD -0.051 95% CI -0.116 to 0.014 P =0.178). No significant differences were noted in frozen versus lyophilized groups with an overall trend towards Fresh FM (RD -0.061 95% CI -0.038 to 0.160 P =0.617). On network meta-analysis, when compared with fresh group, a lower recovery rate was noted with both frozen group (RD -0.06 95% CI -0.11 to 0.00 P =0.05) and lyophilized group (RD -0.16 95% CI -0.27 to -0.05 P =0.01). CONCLUSION: We conclude the efficacy of Frozen and Lyophilized preparations is high with no difference in direct comparison, and the relative efficacy reduction based on network analysis is outweighed by the safety, accessibility, and practicality of Frozen or Lyophilized preparations.

Dual Antiplatelet Therapy Does Not Increase Bleeding Risk in Percutaneous Gastrostomy Tube Placement: Network Meta-Analysis.

BACKGROUND/OBJECTIVE: Gastrostomy tube (G tube) is a commonly performed procedure for nutritional support. Current guidelines recommend discontinuation of dual antiplatelet therapy (DAPT) prior to G tube placement to reduce bleeding risk. AIMS: We aim to compare bleeding risk in single, dual and no antiplatelet therapy during G tube placement. METHODS: We searched PubMed, Embase, Cochrane, and Web of Sciences to include comparative studies evaluating single antiplatelet (aspirin, clopidogrel), dual antiplatelet (DAPT, aspirin and clopidogrel), and no antiplatelet therapy. Direct as well as network meta-analyses comparing these arms were performed. Risk Differences (RD) with confidence intervals were calculated. RESULTS: 12 studies with 8471 patients were included. On direct meta-analysis, there was no significant difference noted between DAPT compared to Aspirin (RD 0.001 95% CI - 0.012 to 0.014, p = 0.87), Clopidogrel (RD 0.001 95% CI - 0.009 to 0.010, p = 0.92) or no antiplatelet group (RD 0.007 95% CI - 0.011 to 0.026, p = 0.44). Results were consistent on network meta-analysis and no difference was noted in bleeding rates when comparing DAPT with Aspirin (RD 0.001, 95% CI - 0.007 to 0.01, p = 0.76), Clopidogrel (RD 0.001, 95% CI - 0.01 to 0.011, p = 0.90) and no antiplatelet group (RD 0.002, 95% CI - 0.007 to 0.012, p = 0.62). CONCLUSION: There is no significant difference in bleeding risk between DAPT, single antiplatelet or no antiplatelet therapy on a population level. On an individual level, risk of ischemic events should be weighed against the risk of bleeding based on patient circumstances and risk profile. Our findings offer to provide additional data to make an informed decision between patients and physicians to make clinical decisions by assessing individual risks and benefits for optimal care of complex patients.

Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis.

BACKGROUND/AIM: Upper gastrointestinal bleeding (UGIB) usually requires esophagogastroduodenoscopy (EGD) for diagnostic and-potentially-therapeutic purposes. However, blood within the gastric lumen may hinder the procedure. Administration of prokinetics like erythromycin has shown efficacy. This network meta-analysis investigates the efficacy of this intervention prior to EGD. METHODS: We performed a systematic literature search of Embase, PubMed/Medline, and other databases through March 8, 2022 to include randomized controlled trials (RCTs) comparing prokinetic use in EGD for UGIB. We used the DerSimonian-Laird approach to pool data and compare outcomes including need for repeat endoscopy and blood transfusion. Pooled prevalence of proportional outcomes, 95% confidence interval (CI), and p-values were calculated. RESULTS: We included eight RCTs with four distinct intervention groups (erythromycin, placebo to erythromycin, nasogastric (NG) lavage and NG lavage + erythromycin) published between 2002 and 2020 with a total of 721 patients (mean age 60.0 ± 3.1 years; 73.2% male). The need for second look endoscopy was significantly lower with erythromycin than placebo (relative risk: 0.42, CI 0.22-0.83, p = 0.01). Using the frequentist approach, the combination of NG lavage and erythromycin (92.2) was rated highest, followed by erythromycin alone (73.1) for higher rates of empty stomach. Erythromycin was rated highest for lower need for packed red blood cell transfusion (72.8) as well as mean endoscopy duration (66.0). CONCLUSION: Erythromycin improved visualization at EGD, reduced requirements for blood transfusion and repeat EGD, and shortened hospital stay. The combination of erythromycin and NG lavage showed reduced mortality.

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.

Predictors of gastrointestinal bleeding in patients following left ventricular assist device implantation: a systematic review and meta-analysis.

Aim: Our study aims to provide a more holistic understanding of the available data and predictive risk factors for gastrointestinal bleed (GIB). Materials & methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science Core Collection and calculated relative risk and meta-regression was utilized to evaluate for risk factors in order to assess the effect of covariates. Results: Our meta-analysis reported a pooled prevalence rate of GIB of 24.4%. Meta-regression analysis did not yield a statistically significant association between GIB and risk factors, including age, gender, hypertension, chronic kidney disease and diabetes. Conclusion: Studies investigating larger sample sizes are required for conclusive findings.

Comparison of Artificial Intelligence With Other Interventions to Improve Adenoma Detection Rate for Colonoscopy: A Network Meta-analysis.

INTRODUCTION: Recent randomized controlled trials (RCTs) and meta-analysis have demonstrated improved adenoma detection rate (ADR) for colonoscopy with artificial intelligence (AI) compared with high-definition (HD) colonoscopy without AI. We aimed to perform a systematic review and network meta-analysis of all RCTs to assess the impact of AI compared with other endoscopic interventions aimed at increasing ADR such as distal attachment devices, dye-based/virtual chromoendoscopy, water-based techniques, and balloon-assisted devices. METHODS: A comprehensive literature search of PubMed/Medline, Embase, and Cochrane was performed through May 6, 2022, to include RCTs comparing ADR for any endoscopic intervention mentioned above. Network meta-analysis was conducted using a frequentist approach and random effects model. Relative risk (RR) and 95% CI were calculated for proportional outcome. RESULTS: A total of 94 RCTs with 61,172 patients (mean age 59.1±5.2 y, females 45.8%) and 20 discrete study interventions were included. Network meta-analysis demonstrated significantly improved ADR for AI compared with autofluorescence imaging (RR: 1.33, CI: 1.06 to 1.66), dye-based chromoendoscopy (RR: 1.22, CI: 1.06 to 1.40), endocap (RR: 1.32, CI: 1.17 to 1.50), endocuff (RR: 1.19, CI: 1.04 to 1.35), endocuff vision (RR: 1.26, CI: 1.13 to 1.41), endoring (RR: 1.30, CI: 1.10 to 1.52), flexible spectral imaging color enhancement (RR: 1.26, CI: 1.09 to 1.46), full-spectrum endoscopy (RR: 1.40, CI: 1.19 to 1.65), HD (RR: 1.41, CI: 1.28 to 1.54), linked color imaging (RR: 1.21, CI: 1.08 to 1.36), narrow band imaging (RR: 1.33, CI: 1.18 to 1.48), water exchange (RR: 1.22, CI: 1.06 to 1.42), and water immersion (RR: 1.47, CI: 1.19 to 1.82). CONCLUSIONS: AI demonstrated significantly improved ADR when compared with most endoscopic interventions. Future RCTs directly assessing these associations are encouraged.

Fatal Venous Gas Embolism During Endoscopic Retrograde Cholangiopancreatography After Simultaneous Deployment of 2 Self-Expandable Metallic Stents.

Gas embolisms are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). While there have been multiple reports of ERCP-associated air embolisms, only 2 case reports using oral cholangioscopy and CO2 insufflation have been reported in the literature. We present a unique case of a fatal CO2 venous air embolism during ERCP without using cholangioscopy and with no intentional CO2 insufflation of the biliary tree.

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.

Does i-scan improve adenoma detection rate compared to high-definition colonoscopy? A systematic review and meta-analysis.

Background and study aims Recent studies evaluated the impact of i-scan in improving the adenoma detection rate (ADR) compared to high-definition (HD) colonoscopy. We aimed to systematically review and analyze the impact of this technique. Methods A thorough search of the following databases was undertaken: PubMed/Medline, EMBASE, Cochrane and Web of Science. Full-text RCTs and cohort studies directly comparing i-scan and HD colonoscopy were deemed eligible for inclusion. Dichotomous outcomes were pooled and compared using random effects model and DerSimonian-Laird approach. For each outcome, relative risk (RR), 95 % confidence interval (CI), and P value was generated. P  < 0.05 was considered statistically significant. Results A total of five studies with six arms were included in this analysis. A total of 2620 patients (mean age 58.6 ±â€Š7.2 years and female proportion 44.8 %) completed the study and were included in our analysis. ADR was significantly higher with any i-scan (RR: 1.20, [CI: 1.06-1.34], P  = 0.003) compared to HD colonoscopy. Subgroup analysis demonstrated that ADR was significantly higher using i-scan with surface and contrast enhancement only (RR: 1.25, [CI: 1.07-1.47], P  = 0.004). Conclusions i-scan has the potential to increase ADR using the surface and contrast enhancement method. Future studies evaluating other outcomes of interest such as proximal adenomas and serrated lesions are warranted.

Hemorrhagic Ascites Is Associated With Reduced Survival in Cirrhosis: A Systematic Review and Meta-Analysis.

Background: Hemorrhagic ascites is characterized as red blood cell count greater than 10,000/mm3. In cirrhosis, ascites is an event of decompensation, and associated with poor prognosis. However, significance of hemorrhagic ascites is unclear. We conducted a systematic review and meta-analysis to evaluate the significance of hemorrhagic ascites in cirrhotic patients. Methods: We conducted a systematic search in Embase, MEDLINE, Cochrane Central Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trial Registry, and Web of Science Core Collection to identify studies till March 2021, which, in patients with cirrhosis, compared outcomes amongst those with hemorrhagic ascites to those with non-hemorrhagic ascites. The primary outcome was 3-year mortality, and secondary outcomes were acute kidney injury (AKI), hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP) and portal vein thrombosis (PVT). Results: Four studies, with 2,058 cirrhosis patients, were included. Among these, 1,488 patients had non-hemorrhagic ascites and 570 had hemorrhagic ascites. We observed no significant differences in AKI (odds ratio (OR) = 2.55; confidence interval (CI): 0.58 - 11.24), HE (OR = 2.52; CI: 0.70 - 9.05), SBP (OR = 1.66; CI: 0.12 - 22.83) and PVT (OR = 0.99; CI: 0.71 - 1.39). Intensive care unit (ICU) stay was significantly higher in patients with hemorrhagic ascites compared to those with non-hemorrhagic ascites (OR = 1.79; CI: 1.37 - 2.36; I2 = 56%). Pooled 3-year mortality was significantly higher in those with hemorrhagic (72.5% (CI: 68.2-76.4%)) when compared to non-hemorrhagic ascites (57.9% (CI: 55.2-60.6%)) (OR = 2.17; CI: 1.71 - 2.74) with low heterogeneity (I2 = 15%). Conclusions: In patients with cirrhosis, hemorrhagic ascites is a poor prognostic marker, which is associated with increased ICU stay and mortality. Prospective studies are needed to further evaluate significance of hemorrhagic ascites in patients with cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt Outcomes in the Elderly Population: A Systematic Review and Meta-Analysis.

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS. Methods: A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years. Results: Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 - 0.953, P = 0.03, I2 = 49%), 30-day mortality (RR: 0.37, CI: 0.188 - 0.74, P = 0.005, I2 = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 - 0.49, P = 0.001, I2 = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years. Conclusion: Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.