Diagnostic accuracy of convolutional neural network-based machine learning algorithms in endoscopic severity prediction of ulcerative colitis: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Endoscopic assessment of ulcerative colitis (UC) can be performed by using the Mayo Endoscopic Score (MES) or the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). In this meta-analysis, we assessed the pooled diagnostic accuracy parameters of deep machine learning by means of convolutional neural network (CNN) algorithms in predicting UC severity on endoscopic images. METHODS: Databases including MEDLINE, Scopus, and Embase were searched in June 2022. Outcomes of interest were the pooled accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Standard meta-analysis methods used the random-effects model, and heterogeneity was assessed using the I2statistics. RESULTS: Twelve studies were included in the final analysis. The pooled diagnostic parameters of CNN-based machine learning algorithms in endoscopic severity assessment of UC were as follows: accuracy 91.5% (95% confidence interval [CI], 88.3-93.8; I2 = 84%), sensitivity 82.8% (95% CI, 78.3-86.5; I2 = 89%), specificity 92.4% (95% CI, 89.4-94.6; I2 = 84%), PPV 86.6% (95% CI, 82.3-90; I2 = 89%), and NPV 88.6% (95% CI, 85.7-91; I2 = 78%). Subgroup analysis revealed significantly better sensitivity and PPV with the UCEIS scoring system compared with the MES (93.6% [95% CI, 87.5-96.8; I2 = 77%] vs 82% [95% CI, 75.6-87; I2 = 89%], P = .003, and 93.6% [95% CI, 88.7-96.4; I2 = 68%] vs 83.6% [95% CI, 76.8-88.8; I2 = 77%], P = .007, respectively). CONCLUSIONS: CNN-based machine learning algorithms demonstrated excellent pooled diagnostic accuracy parameters in the endoscopic severity assessment of UC. Using UCEIS scores in CNN training might offer better results than the MES. Further studies are warranted to establish these findings in real clinical settings.

Pooled rates of adenoma detection by colonoscopy in asymptomatic average-risk individuals with positive fecal immunochemical test: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Current adenoma detection rate (ADR) benchmarks for colonoscopy in individuals positive for a fecal immunochemical test (FIT) are ≥45% in men and ≥35% in women. These are based on weak, low-quality evidence. We performed a meta-analysis to ascertain the pooled ADR in FIT-positive colonoscopy. METHODS: Major databases like PubMed, EMBASE, and Web of Science were searched in October 2021 for studies reporting on ADR of colonoscopy in a FIT-positive population. Meta-analysis was performed by standard methodology using the random-effects model. Heterogeneity was assessed by I2 and 95% prediction interval statistics. RESULTS: Thirty-four high-quality studies that included more than 6 million asymptomatic average-risk individuals were analyzed; 2,655,345 individuals completed a screening FIT test. The pooled FIT screening rate was 69.8% (95% CI, 62.8-76.1), the pooled FIT positivity rate was 5.4% (95% CI, 4.3-6.9), and the colonoscopy completion rate was 85% (95% CI, 82.8-86.9). The pooled ADR was 47.8% (95% CI, 44.1-51.6), pooled advanced ADR was 25.3% (95% CI, 22-29), and the pooled colorectal cancer detection rate was 5.1% (95% CI, 4.4-5.9). The pooled ADR in men was 58.3% (95% CI, 52.8-63.6) and in women was 41.9% (95% CI, 36.4-47.6). The pooled ADR with qualitative FIT assessment was 67.7% (95% CI, 50.7-81), with 1-stool sample FIT was 52.8% (95% CI, 48.8-56.8), and at a cutoff threshold of 100 ng hemoglobin/mL was 52.1% (95% CI, 47-57.1). Based on time-period cumulative analysis, the ADR improved over time from 30.5% (95% CI, 24.6-37.2) to 47.8% (95% CI, 44.1-51.6). CONCLUSIONS: This meta-analysis supports the current ADR benchmarks for colonoscopy in FIT-positive individuals. Excellent pooled ADR parameters were demonstrated with qualitative assessment of 1 stool sample at a test cutoff value of 100 ng hemoglobin/mL, and ADR per endoscopist improved over time.

Intracystic Glucose Levels in Differentiating Mucinous From Nonmucinous Pancreatic Cysts: A Systematic Review and Meta-analysis.

BACKGROUND: Mucinous pancreatic cysts are well reported to transform into pancreatic adenocarcinoma, whereas nonmucinous cysts are mostly benign with low risk for malignant transformation. Nonsurgical methods of differentiating mucinous and nonmucinous pancreatic cysts are challenging and entail a multi investigational approach. Low intracystic glucose levels have been evaluated in multiple studies for its accuracy in differentiating mucinous from nonmucinous cysts of the pancreas. METHODS: Multiple databases were searched and studies that reported on the utility of intracystic glucose levels in diagnosing mucinous pancreatic cysts were analyzed. Meta-analysis was conducted using the random-effects model, heterogeneity was assessed by I2%, and pooled diagnostic test accuracy values were calculated. RESULTS: Seven studies were included in the analysis from an initial total of 375 citations. The pooled sensitivity of low glucose in differentiating mucinous pancreatic cyst was 90.5% [95% confidence interval (CI): 88.1-92.5; I2=0%] and the pooled specificity was 88% (95% CI: 80.8-92.7; I2=79%). The sensitivity at a glucose cut-off of 50 was 90.1% (95% CI: 87.2-92.5; I2=0%) and the specificity was 85.3% (95% CI: 76.8-91.1; I2=76%). The sensitivity of glucose levels in pancreatic cyst fluid taken by endoscopic ultrasound guided fine-needle aspiration was 90.8% (95% CI: 87.9-93.1; I2=0%) and the specificity was 90.5% (95% CI: 81.7-95.3; I2=83%). The sensitivity of point-of-care glucometers was 89.5% (95% CI: 87.9-93.1; I2=0%) and specificity was 83.9% (95% CI: 68.5-92.6; I2=43%). CONCLUSIONS: Low glucose level at a cut-off of 50 mg/dL on fluid samples collected by endoscopic ultrasound guided fine-needle aspiration and analyzed by point-of-care glucometer achieves excellent diagnostic accuracy in differentiating mucinous pancreatic cysts.

Photodynamic Therapy (PDT), Radiofrequency Ablation (RFA) With Biliary Stents in Palliative Treatment of Unresectable Extrahepatic Cholangiocarcinoma: A Systematic Review and Meta-analysis.

BACKGROUND AND AIM: Extrahepatic unresectable cholangiocarcinoma carries a dismal prognosis. In addition to biliary drainage by stent placement; photodynamic therapy (PDT) and radiofrequency ablation (RFA) have been tried to prolong survival. In this meta-analysis, we appraise the current known data on the use of PDT, RFA in the palliative treatment of extrahepatic unresectable cholangiocarcinoma. METHODS: We searched multiple databases from inception through July 2020 to identify studies that reported on PDT and RFA. Pooled rates of survival, stent patency, 30-, 90-day mortality, and adverse events were calculated. Study heterogeneity was assessed using I2% and 95% prediction interval. RESULTS: A total of 55 studies (2146 patients) were included. A total of 1149 patients underwent treatment with PDT (33 studies), 545 with RFA (22 studies), and 452 patients with stent-only strategy. The pooled survival rate with PDT, RFA, and stent-only groups was 11.9 [95% confidence interval (CI): 10.7-13.1] months, 8.1 (95% CI: 6.4-9.9) months, and 6.7 (95% CI: 4.9-8.4) months, respectively. The pooled time of stent patency with PDT, RFA, and stent-only groups was 6.1 (95% CI: 4.2-8) months, 5.5 (95% CI: 4.2-6.7) months, and 4.7 (95% CI: 2.6-6.7) months, respectively. The pooled rate of 30-day mortality with PDT was 3.3% (95% CI: 1.6%-6.7%), with RFA was 7% (95% CI: 4.1%-11.7%) and with stent-only was 4.9% (95% CI: 1.7%-13.1%). The pooled rate of 90-day mortality with PDT was 10.4% (95% CI: 5.4%-19.2%) and with RFA was 16.3% (95% CI: 8.7%-28.6%). CONCLUSION: PDT seemed to demonstrate better overall survival and 30-day mortality rates than RFA and/or stent-only palliation.

Outcomes of liver transplantation in patients 70 years or older: a systematic review and meta-analysis.

INTRODUCTION AND OBJECTIVES: The rate of liver transplantation is increasing among the elderly population; however, data is limited on the post-liver transplantation outcomes in patients ≥70 years. Given the scarcity in liver allograft resources, a meta-analysis on the outcomes of liver transplantation in patients ≥70 years is warranted. MATERIALS AND METHODS: Multiple databases were searched through March 2022 for studies that reported on the outcomes of liver-transplantation in patients ≥70 years. Meta-analysis was conducted using the random-effects model and heterogeneity was assessed using the I2 statistics. RESULTS: Ten studies were included that analyzed 162,725 patients. The pooled rate of 1-year, 3-years and 5-years post liver transplant survival for patients ≥70 years was 78.7% (72.6-83.7; I2=74%), 61.2% (52.3-69.5; I2=87%), and 48.9% (39.3-58.6; I2=96%), respectively. The corresponding 1-year, 3-years and 5-years survival for patients <70 years were 86.6% (82.4-89.9; I2=99%), 73.2% (63-81.3; I2=99%), and 70.1% (66.8-73.2; I2=99%); respectively. Descriptive p-values of comparison were statistically significant at 1-year and 5-years (p = 0.02 and <0.001). The pooled rate of perioperative complications in patients ≥70 years was 40.7% (26.2-57; I2=93%). The pooled rate of graft failure in patients ≥70 years was 6.7% (3.3-13.1; I2=93%) and in patients <70 years was 3.7% (1-12.4; I2=99%). The pooled rate of perioperative mortality in patients ≥70 years was 16.6% (7.6-32.5; I2=99%) and in patients <70 years was 0.8% (0-33.1; I2=88%). CONCLUSION: Patients ≥70 years undergoing liver transplantation seem to demonstrate significantly lower 1-year and 5-year survival rates as compared to patients <70 years, albeit limited by heterogeneity.

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end. METHODS: We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity. RESULTS: Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P = .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P = .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P = .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7). CONCLUSIONS: EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.

Endoscopic resection of colon dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) is a well-known risk factor for colorectal cancer (CRC). Current guidelines propose complete endoscopic resection of dysplasia in IBD patients with close endoscopic follow-up. Current data on the risk of neoplasia after endoscopic resection of dysplasia in IBD patients are limited. METHODS: Multiple databases were searched from inception through August 2019 to identify studies that reported on incidence and/or recurrence of neoplasia after resection of dysplasia in patients with IBD. Outcomes from the included studies were pooled to estimate the risk of neoplasia after dysplasia resection in IBD patients. RESULTS: From 18 studies, 1037 IBD patients underwent endoscopic resection for a total of 1428 colonic lesions. After lesion resection, the pooled risk (rate per 1000 person-years of follow-up) of CRC was 2 (95% confidence interval [CI], 0-3), the pooled risk of high-grade dysplasia was 2 (95% CI, 1-3), and the pooled risk of any lesion was 43 (95% CI, 30-57). Meta-regression analysis based on lesion location (right, left), lesion size (mean and/or median size in mm), lesion type (Paris type I, Paris type II), endoscopic resection technique (EMR, endoscopic submucosal dissection, or polypectomy), and lesion histology (low-grade dysplasia, high-grade dysplasia) did not influence the reported outcomes. CONCLUSIONS: Risk of CRC after dysplasia resection in IBD patients appears to be low, supporting the current strategy of resection and surveillance.

High pooled performance of convolutional neural networks in computer-aided diagnosis of GI ulcers and/or hemorrhage on wireless capsule endoscopy images: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Diagnosis of GI ulcers and/or hemorrhage by wireless capsule endoscopy (WCE) is limited by the physician-dependent, tedious, time-consuming process of image and/ or video classification. Computer-aided diagnosis (CAD) by convolutional neural network (CNN)-based machine learning may help reduce this burden. Our aim was to conduct a meta-analysis and appraise the reported data. METHODS: Multiple databases were searched (from inception to November 2019), and studies that reported on the performance of CNN in the diagnosis of GI ulcerations and/or hemorrhage on WCE were selected. A random-effects model was used to calculate the pooled rates. In cases where multiple 2 × 2 contingency tables were provided for different thresholds, we assumed the data tables were independent from each other. Heterogeneity was assessed by I2% and 95% prediction intervals. RESULTS: Nine studies were included in our final analysis that evaluated the performance of CNN-based CAD of GI ulcers and/or hemorrhage by WCE. The pooled accuracy was 95.4% (95% confidence interval [CI], 94.3-96.3), sensitivity was 95.5% (95% CI, 94-96.5), specificity was 95.8% (95% CI, 94.7-96.6), positive predictive value was 95.8% (95% CI, 90.5-98.2), and negative predictive value was 96.8% (95% CI, 94.9-98.1). I2% heterogeneity was negligible except for the pooled positive predictive value. CONCLUSIONS: Based on our meta-analysis, CNN-based CAD of GI ulcerations and/or hemorrhage on WCE achieves a high-level performance. The quality of the evidence is robust, and therefore CNN-based CAD has the potential to become the first choice of machine learning to optimize WCE image/video reading.

Drug Eluting Versus Covered Metal Stents in Malignant Biliary Strictures-Is There a Clinical Benefit?: A Systematic Review and Meta-Analysis.

GOALS/BACKGROUND: Patients with malignant biliary obstruction (MBO) often require transpapillary stenting for symptomatic relief and biliary decompression. Plastic stents and uncovered metal stents are now replaced by covered self-expanding metal stents (SEMS). However, stent occlusion from tumor overgrowth and chronic inflammation continues to be an issue. Drug-eluting stents (DES), through an antitumor paclitaxel membrane, have been used to combat this problem. The aim of this study was to conduct a meta-analysis comparing DES to SEMS in MBO. STUDY: Multiple databases were searched to identify studies that compared the clinical outcomes of SEMS and DES in patients with MBO. Random-effects model was used to calculate the pooled odds ratio and the pooled individual outcomes. Our primary goals were to assess the stent patency and overall survival in days. Secondary outcomes assessed the individual reported adverse events and/or complications. RESULTS: Five studies including 348 patients (175 males and 173 females) were included. The pooled odds ratio of stent patency was 1.03 (95% confidence interval: 0.68-1.54, P=0.9) and overall survival was 1.16 (95% confidence interval: 0.63-2.11, P=0.6). The pooled rate of stent patency was 168.3 (95% 140.7-196.4) days for DES and 149.4 (117.6-181.2) days for SEMS. The pooled rate of overall survival was 267.2 (206.2-328.2) days for DES and 218.2 (148.5-287.8) days for SEMS. CONCLUSION: On the basis of this meta-analysis, DES and SEMS seem to demonstrate comparable clinical outcomes in patients with malignant biliary strictures. Reported adverse events and/or complications were comparable as well.

Safety and Efficacy of Biological Therapy in Chronic Antibiotic Refractory Pouchitis: A Systematic Review With Meta-analysis.

BACKGROUND: Pouchitis is the most common long-term complication after ileal pouch-anal anastomosis in patients with ulcerative colitis. Those with ≥3 episodes of pouchitis/year and symptoms despite antibiotics are considered to have chronic antibiotic refractory pouchitis (CARP). While several agents including probiotics, steroids and immunomodulators have been used, treatment of CARP remains challenging. We conducted a systematic review and meta-analysis evaluating the safety and efficacy of various biological agents in treatment of CARP. METHODS: Multiple databases were searched through June 2020 for studies that reported the efficacy and safety of biological therapy including antitumor necrosis factor-alpha agents [infliximab (IFX) and adalimumab (ADA)], vedolizumab (VDZ), and ustekinumab in CARP. We excluded studies on Crohn's like and/or other inflammatory complications of the pouch. Meta-analysis was performed to calculate pooled rates of clinical as well as endoscopic improvement and remission. RESULTS: We included 15 studies with 311 patients in our final analysis. Ninety-two patients were treated with IFX, 42 with ADA, 144 with VDZ and 33 with ustekinumab. Pooled rate of clinical improvement was 71.4%, 58.2%, 47.9% and clinical remission was 65.7%, 31%, 47.4% with IFX, ADA, and VDZ, respectively. Pooled rate of endoscopic improvement was achieved in 61.2% patients treated with VDZ while endoscopic remission was achieved in 70.3% patients treated with IFX. Adverse events were reported in 3.9% patients. CONCLUSION: Biologic therapy is safe and effective in the treatment of CARP.

Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: systematic review and meta-analysis.

BACKGROUND: Gastric variceal bleeding carries significant mortality in the setting of portal hypertension. Among the endoscopic treatment options, endoscopic ultrasound (EUS)-guided glue and/or coil injection is a novel approach, but its role in the treatment of gastric varices is not established due to a lack of robust data. METHODS: We conducted a comprehensive search of several databases (inception to June 2019) to identify studies evaluating EUS in the treatment of gastric varices. Our primary goals were to estimate the pooled rates of treatment efficacy, obliteration and recurrence of gastric varices, early and late rebleeding, and adverse events with EUS-guided therapy in gastric varices. We also searched for studies that evaluated direct endoscopic glue (END-glue) injection for treatment of gastric varices, and used the pooled rates as comparators. RESULTS: 23 studies (851 patients) evaluating EUS-guided therapy were included. The pooled treatment efficacy was 93.7 % (95 % confidence interval [CI] 89.5 - 96.3, I 2 = 53.7), gastric varices obliteration was 84.4 % (95 %CI 74.8 - 90.9, I 2 = 77), gastric varices recurrence was 9.1 % (95 %CI 5.2 - 15.7, I 2 = 32), early rebleeding was 7.0 % (95 %CI 4.6 - 10.7, I 2 = 0), and late rebleeding was 11.6 % (95 %CI 8.8 - 15.1, I 2 = 22). The rates were comparable to END-glue therapy (28 studies, 3467 patients) except for obliteration, which was significantly better with EUS-guided therapy. On subgroup analysis, EUS-coil/glue combination showed superior outcomes. CONCLUSIONS: EUS-guided therapy demonstrated clinical efficacy for treatment of gastric varices in terms of obliteration, recurrence, and long-term rebleeding, and may be superior to END-glue.

Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis.

BACKGROUND: Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy. METHODS: We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis. RESULTS: 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 - 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 - 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 - 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 - 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 - 75.7; I 2 90). CONCLUSION: Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.

Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.

BACKGROUND: Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results. METHODS: We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence. RESULTS: 1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 - 85.5, I 2 = 29) and 88.1 % (95 %CI 83.6 - 91.4, I 2 = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 - 96.9, I 2 = 0) and 96.7 % (95 %CI 94.0 - 98.2, I 2 = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 - 99.1, I 2 = 0) and 89.3 % (95 %CI 86.6 - 91.5, I 2 = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 - 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 - 6.8) and 3.7 % (95 %CI 2.3 - 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 - 10.0). CONCLUSION: EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.

Venous Thromboembolism in Hospitalized COVID-19 Patients.

BACKGROUND: Venous thromboembolism (VTE) is increasingly reported in seriously ill patients with COVID-19 infection. Incidence of VTE has been reported before and results varied widely in study cohorts. AREA OF UNCERTAINTY: Incidence of major VTE (segmental pulmonary embolism and above and proximal deep vein thrombosis) which is a contributor to mortality and morbidity is not known. Also, data is unclear on the optimal anticoagulation regimen to prevent VTE. DATA SOURCES: Multiple databases including PubMed were searched until May 12, 2020, to include studies reporting VTE in hospitalized COVID-19 adult patients. MOOSE guidelines were followed in selection, and 11 studies were included. We conducted a systematic review and meta-analysis to quantitatively assess the VTE burden in hospitalized COVID-19 patients and potential benefits of therapeutic dosing of anticoagulation compared with prophylaxis dosing for VTE prevention. THERAPEUTIC ADVANCES: Many societies and experts recommend routine prophylactic anticoagulation with heparin for VTE prevention in hospitalized COVID-19 patients. In this meta-analysis, the pooled rate of major VTE was 12.5% in hospitalized patients and 17.2% in intensive care unit patients. When therapeutic anticoagulation dosing was compared with prophylactic anticoagulation, the pooled odds ratio of VTE was 0.33 (95% confidence interval 0.14-0.75; P = 0.008, I = 0%) suggesting statistical significance with therapeutic dosing of anticoagulation for primary prevention of VTE in all hospitalized patients. However, this should be interpreted with caution as the bleeding events and safety profile could not be ascertained because of lack of adequate information. We recommend applying this finding to hospitalized COVID 19 patients only after carefully weighing individual bleeding risks and benefits. CONCLUSION: Major VTE events, especially pulmonary embolism, seem to be high in COVID-19 patients admitted to the intensive care unit. Therapeutic anticoagulation dosing seems to significantly benefit the odds of preventing any VTE when compared with prophylactic dosing in all hospitalized patients.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group.

BACKGROUND AND AIMS: Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. RESULTS: Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis.

BACKGROUND AND AIMS: EUS-guided liver biopsy (LB) is an emerging technique over conventional percutaneous (PC) or transjugular (TJ) approaches. Recent studies have reported that EUS-guided LB may have a better safety profile than PC LB or TJ LB without compromising diagnostic yield, and the outcomes are varied with respect to the types of biopsy needles. We performed a systematic review and meta-analysis to estimate the diagnostic yield, specimen adequacy, and adverse events associated with EUS-guided LB. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception to June 2018) to identify studies that reported on EUS-guided LB. The primary outcome was to estimate the pooled rates of successful diagnosis made and insufficient specimen obtained. The secondary outcome was to estimate the pooled rate of adverse events. A subgroup analysis compared the outcomes based on the type of biopsy needle. RESULTS: A total of 9 study arms with 437 patients were included. The pooled rate of successful histologic diagnoses was 93.9% (95% confidence interval [CI], 84.9-97.7), with heterogeneity I2 of 75.3%. The pooled rate of insufficient specimen obtained was 10.1% (95% CI, 3.5-25.8), with I2 = 71.6%. The pooled rate of adverse events with EUS-guided LB was 2.3% (95% CI; 1.1-4.8, I2 = 0). On subgroup analysis, the adverse events rate with a 19-gauge FNA needle (vs other core biopsy needles) was 0.9% (vs 2.7%, P = .28), and the rate of diagnostic yield was 95.8% (vs 92.7%, P = .59). The rate of insufficient specimen was significantly lower with an FNA needle compared with the core needle (4% vs 20%, P = .03). CONCLUSION: With a histologic diagnosis rate of 93.9% and adverse event rate of 2.3%, EUS-guided LB appears to be both effective and safe. A 19-gauge FNA needle provides significantly better biopsy specimens and seems to have better outcomes compared with other core biopsy needles.

Efficacy and Safety of Endoscopic Ultrasound-guided Choledochoduodenostomy: A Systematic Review and Meta-Analysis.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography is the preferred method in biliary drainage. Endoscopic ultrasound (EUS) guidance has shown tremendous success in situations where endoscopic retrograde cholangiopancreatography fails or is contraindicated. EUS-guided choledochoduodenostomy (CDD) in particular is gathering a lot of interest due to its ease, and high rates of success. The reported adverse events with this procedure have been inconsistent among studies. METHODS: We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the risk of adverse events, and the commonly reported subtype of adverse events in EUS-CDD. The secondary outcome was to estimate the pooled technical and clinical success rates. RESULTS: Thirteen studies including 572 patients underwent biliary drainage with EUS-CDD. The pooled rate of all adverse events was 0.136 (95% confidence interval, 0.097-0.188; P=0.01) with moderate heterogeneity (I=56.9), and pooled rate of cholangitis was 4.2%, bleeding was 4.1%, bile leak was 3.7%, and perforation was 2.9%. On subgroup analysis, the pooled rate of adverse events with the use of lumen-apposing metal stent was 9.3% (95% confidence interval, 4.8-17.3). CONCLUSIONS: On the basis of our analysis EUS-CDD has an adverse event risk of 13.4%, which is lowest reported in literature so far. Reported adverse rates appeared to be lower with the use of lumen-apposing metal stent, except for perforation.

Lumen-apposing Metal Stents, Fully Covered Self-expanding Metal Stents, and Biodegradable Stents in the Management of Benign of GI Strictures: A Systematic Review and Meta-Analysis.

BACKGROUND: Refractory benign gastrointestinal (GI) strictures are difficult to treat and placement of a stent is a commonly sought resort. Stents used for this purpose are fully covered self-expanding metal stent (FCSEMS), a biodegradable stent (BDS) and recently, a lumen-apposing metal stent (LAMS). There is no data comparing these stents to this end. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2018) to identify studies that reported on the performance of FCSEMS, BDS, and LAMS in the treatment of refractory benign GI strictures. Our goals were to evaluate the pooled rate of technical success, clinical success, and adverse events with these stents and compare the outcomes between them. RESULTS: A total of 31 studies were analyzed. In total, 14 (342 patients), 11 (226 patients), and 8 studies (192 patients) reported the use of FCSEMS, BDS, and LAMS, respectively. The pooled rate of technical success was 96.5% [95% confidence interval (CI): 93.5-98.1], 91.9% (95% CI: 85.6-95.6), and 97.6% (95% CI: 94.0-99.0) with FCSEMS, BDS, and LAMS respectively. No statistical significance to the difference was noted. The pooled rate of clinical success was 48.4% (95% CI: 37.1-59.8), 34.9% (95% CI: 23.6-48.1), and 78.8% (95% CI: 65.8-87.8) with FCSEMS, BDS, and LAMS, respectively. Statistical significance was noted in LAMS versus FCSEMS (P=0.001) and LAMS versus BDS (P=0.001). LAMS demonstrated statistically better outcomes in regards to stent migration and postprocedure pain when compared with FCSEMS and BDS. CONCLUSION: Our study demonstrates that LAMS gives better clinical outcomes in the treatment of refractory benign GI strictures when compared with FCSEMS and BDS. Variability in the site, as well as the length of stricture, indirect comparison, and heterogeneity, were the limitations of our study.

Fecal microbiota transplant delivered via invasive routes in irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) results in significant loss of quality of life. Management guidelines do not recommend fecal microbiota transplant (FMT) for IBS based on weak evidence as refined data is lacking. We performed a systematic review and meta-analysis to ascertain the pooled clinical outcomes of FMT in IBS, delivered via invasive routes. METHODS: Multiple databases were searched through January 2023 to identify studies that reported on FMT treatment in IBS by invasive routes. Standard meta-analysis methodology using the random-effects model was used. Heterogeneity was assessed by I2% and 95% predication interval. RESULTS: Five studies were included. As many as 377 IBS patients were assessed, of which 238 received FMT and 139 received placebo. One study used nasojejunal tubes, one esophagogastroduodenoscopy and three colonoscopy for FMT delivery. FMT via colonoscopy was performed as a one-time procedure instilled into the cecum. Two studies used 30 g of stool from a single universal donor and one study used 50-80 g of pooled donor feces. The pooled odds ratio of improvement in IBS symptoms with FMT was significantly better as compared to that of placebo OR = 2.9 (95% CI [1.6-5.2, I2 = 62%, p < 0.001]). This was true for studies that exclusively used colonoscopy (OR = 2.1 [1.1-4.2, p = 0.04]). In the FMT arm, 10 patients (10.6%) reported abdomen pain and worsening of symptoms with bloating and six patients (6.3%) reported diarrhea. CONCLUSION: FMT delivered via invasive routes, especially colonoscopy, demonstrated significant improvement in IBS symptoms. A single FMT consisting of 30 g or more of single universal donor feces instilled into the cecum is the predominant modality.

Role of dietary iron revisited: in metabolism, ferroptosis and pathophysiology of cancer.

Iron is the most abundant metal in the human body. No independent life forms on earth can survive without iron. However, excess iron is closely associated with carcinogenesis by increasing oxidative stress via its catalytic activity to generate hydroxyl radicals. Therefore, it is speculated that iron might play a dual role in cells, by both stimulating cell growth and causing cell death. Dietary iron is absorbed by the intestinal enterocytes in the form of ferrous ion which forms cLIP. Excess iron stored in the form of Ferritin serves as a reservoir under iron depletion conditions. Ferroptosis, is an iron-dependent non-mutational form of cell death process and is suppressed by iron-binding compounds such as deferoxamine. Blocking transferrin-mediated iron import or recycling of iron-containing storage proteins (i.e., ferritin) also attenuates ferroptosis, consistent with the iron-dependent nature of this process. Unsurprisingly, ferroptosis also plays a role in the development of cancer and maybe a beneficial strategy for anticancer treatment. Different lines of evidence suggest that ferroptosis plays a crucial role in the suppression of tumorigenesis. In this review, we have discussed the pros and cons of iron accumulation, utilization and, its role in cell proliferation, ferroptosis and pathophysiology of cancer.