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.

Caregiver Burden in Gastroparesis and GERD: Correlation with Disease Severity, Healthcare Utilization and Work Productivity.

BACKGROUND: Caregiver burden can be significant in chronic gastrointestinal diseases. No studies have been performed to evaluate caregiver burden in gastroparesis or gastroesophageal reflux disease (GERD). AIMS: (1) Assess the caregiver burden in gastroparesis and GERD patients and healthy volunteers (HVs); (2) correlate the caregiver burden of these patients to the severity of patients' symptoms, healthcare utilization, and work productivity of the patients and the caregivers. METHODS: Patients with gastroparesis and GERD, seen between June 2018 and November 2018, completed Patient Assessment of Gastrointestinal Symptoms, Work Productivity and Activity Impairment (WPAI) and healthcare utilization questionnaires. The caregivers of these patients completed Zarit Burden Interview (ZBI) and WPAI questionnaire. HVs and their potential caregivers also completed these questionnaires. RESULTS: Forty-seven patients (gastroparesis = 31, GERD = 17), 12 HVs, and their caregivers completed questionnaires. Caregivers of gastroparesis patients reported high burden on ZBI (27.7 ± 2.9), greater than the caregivers of GERD (14.9 ± 2.5) and HVs (5.5 ± 1.6, p < 0.01). Among all patients, the caregiver burden had a strong correlation with patients' Gastroparesis Cardinal Symptom Index (GCSI) total score (rs = 0.63, p < 0.01) and moderate correlations with the number of patients' physician office visits (rs = 0.46, p < 0.01) and the number of work hours missed by caregivers due to patients' symptoms (rs = 0.36, p = 0.04). Using multivariable regression, both presence of gastroparesis and other comorbidities significantly predicted caregiver burden, F(2, 33) = 15.94, p < 0.0001, R2 = 0.491. CONCLUSIONS: Caregivers of gastroparesis patients have high caregiver burden that strongly correlates with patients' GCSI total score. Interventions to reduce symptom severity of Gp patients may reduce the caregiver burden.

Inverse Lindley power series distributions: a new compounding family and regression model with censored data.

This paper introduces a new class of distributions by compounding the inverse Lindley distribution and power series distributions which is called compound inverse Lindley power series (CILPS) distributions. An important feature of this distribution is that the lifetime of the component associated with a particular risk is not observable, rather only the minimum lifetime value among all risks is observable. Further, these distributions exhibit an unimodal failure rate. Various properties of the distribution are derived. Besides, two special models of the new family are investigated. The model parameters of the two sub-models of the new family are obtained by the methods of maximum likelihood, least square, weighted least square and maximum product of spacing and compared them using the Monte Carlo simulation study. Besides, the log compound inverse Lindley regression model for censored data is proposed. Three real data sets are analyzed to illustrate the flexibility and importance of the proposed models.

Metoclopramide for the treatment of diabetic gastroparesis.

Introduction: Gastroparesis is a chronic disorder of the stomach characterized by delayed gastric emptying without mechanical obstruction. Diabetes is the most commonly known cause of gastroparesis. Management of diabetic gastroparesis involves lifestyle modifications, glycemic control, pharmacological drugs, and for refractory cases surgical treatments. Metoclopramide remains the only drug approved by the Food and Drug Administration for diabetic gastroparesis. The aim of this article is to provide a concise review of the pharmacology, clinical efficacy and tolerability of metoclopramide. Areas covered: We searched PubMed using the key words 'metoclopramide', 'diabetic gastroparesis', and 'gastric emptying'. The relevant articles and their bibliography were reviewed. Metoclopramide acts on several different receptors; primarily as a dopamine receptor antagonist, both peripherally improving gastric emptying, and centrally resulting in an anti-emetic effect. Metoclopramide side effects, mostly related to its ability to cross the blood-brain barrier, include drowsiness, restlessness, hyperprolactinemia, and tardive dyskinesia (TD), a movement disorder that may be irreversible. Expert opinion: Metoclopramide carries a black box warning for use >12 weeks due to the risk of TD. However, gastroparesis patients experience chronic symptoms often requiring prolonged treatments. Physicians and patients look forward to FDA approval of new agents for gastroparesis with better efficacy and safety profile.

Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections.

Lumen-apposing metal stents (LAMS) are increasingly being used in the drainage of pancreatic walled-off necrosis (WON). Best choice of stent is subject to argument, and studies are varied in the reported outcomes between LAMS and plastic stents (PS) to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception through July 2018) to identify studies that reported on the use of LAMS and PS in WON drainage. Studies published since the release of the revised Atlanta classification for pancreatic fluid collections (2014 to current) were included in the analysis. The outcomes were to estimate and compare the pooled rates of clinical success, and adverse-events. A total of 9 studies (737 patients) for LAMS and 6 studies (527 patients) for PS were included in the analysis. The pooled rate of clinical-success with LAMS was 88.5% (95% CI 82.5-92.6, I2 = 71.7) and with PS was 88.1% (95% CI 80.5-93.0, I2 = 78.1) and the difference was not statistically significant, P = 0.93. No difference was noted in the pooled rates of all adverse-events, LAMS: 11.2% (6.8-17.9, I2 = 82.0); vs PS: 15.9% (8.4-27.8, I2 = 78.8); P = 0.38. Based on our meta-analysis, LAMS and PS demonstrate equal clinical outcomes and equal adverse-events in the drainage of pancreatic WON.

Adverse events with lumen-apposing metal stents in endoscopic gallbladder drainage: A systematic review and meta-analysis.

BACKGROUND: Lumen-apposing metal stents (LAMS) are rapidly being used in endoscopic interventional drainage procedures and have started to replace the self-expanding metal stents (SEMSs). Its use in gallbladder drainage (GBD) is limited by lack of good-quality studies, and data are scarce on its safety. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, Embase, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of LAMS in GBD. The outcomes measured were the pooled rates of all adverse events (AEs), pooled rates of early AEs and pooled rates of delayed AEs. RESULTS: A total of 8 studies (393 patients) were included. The pooled rate of all AEs was 12.7% (95% CI 8.4-18.7, I2= 7.7) compared to 17.5% (95% CI 10.2-28.2, I2= 65.1) with other SEMS, P = 0.39. The rate of early AEs with LAMS in endoscopic ultrasound-GBD (EUS-GBD) was 6.5% (95% CI 4.2-10, I2= 1.2), and the rate of delayed AEs was 8.3% (95% CI 5.8-11.9, I2 = 4.8). The rate of recurrent cholecystitis and/or cholangitis was 4.6% (95% CI 2.6-9.5, I2= 0) and the pooled rate of death was 5% (95% CI 2.6-9.5, I2 = 36.4). CONCLUSION: We report an overall AE rate of 13% with LAMS in EUS-GBD. Early AE risk appears to be 6.5% and delayed AE risk appears to be 8%. Our results are analyzed out of good-quality studies, with minimal to zero heterogeneity.

Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis.

Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 - 96.6, I2 = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 - 96.2, I2 = 88.4).

EUS versus percutaneous management of postoperative pancreatic fluid collection: A systematic review and meta-analysis.

Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management options are time-consuming and severely affect patient's quality of life. Surgical and/or percutaneous drainage (PCD) is the traditional mainstay of treatment. Studies have shown that EUS could have a role to play in the management of POPFC. Data are limited in the comparison of clinical outcomes with EUS as compared to PCD to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, LILACS, and Web of Science databases (earliest inception through September 2018) to identify studies that reported on the clinical outcomes of EUS and PCD in the management of POPFC. The goals were to estimate and compare the pooled rates of technical success, clinical success, adverse events, and POPFC recurrence with EUS and PCD. A total of 13 studies were included in the analysis. Ten studies (239 patients) used EUS and 6 studies (267 patients) used PCD in the management of POPFC. The pooled rate of clinical success with EUS was 93.2% (95% confidence interval [CI] 88.2-96.2, I2 = 0) and with PCD was 79.8% (95% CI 70-87, I2 = 74). The difference was statistically significant, P = 0.002. Recurrence rate was significantly lower with EUS as compared to PCD (9.4%: 95% CI 5.2-16.5 vs. 25.7%: 95% CI 24.3-41.7; P = 0.02). Pooled rates of technical success and adverse events were similar with EUS and PCD. Our meta-analysis shows that EUS has significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.

Anomalous Origin of Coronary Arteries Arising from the Right Coronary Cusp: A Rare Presentation.

The anomalous origin of coronaries is rare. The purpose of this case report is to show a rare anomalous origin of coronaries. A 64-year-old female presented with chest pain that was typical in nature. The patient had left heart catheterization that showed an anomalous origin of coronaries, where all the coronaries were arising from the right coronary cusp. The patient had a significant disease in the distal left anterior descending artery, but it was a small vessel. Medical management was chosen. This is a rare presentation of the coronary anatomy.

Antidromic Atrioventricular Reentry Tachycardia with Wolff Parkinson White Syndrome: A Rare Beast.

Orthodromic atrioventricular reentrant tachycardia (AVRT) is the second-most-common form of supraventricular tachycardia (SVT) and is inducible in approximately 55% of individuals with Wolff Parkinson White (WPW) syndrome. Antidromic AVRT, where the accessory atrioventricular connection is used as the antegrade limb and the atrioventricular node serves as the retrograde limb of the circuit, has been clinically documented in less than 5% of patients with WPW syndrome and may be induced in less than 10% of these WPW cases in the electrophysiology laboratory. Left lateral pathways are considered more frequent and septal locations are less common when associated with antidromic AVRT. We report a case of 21-year-old male with a history of WPW syndrome who had undergone a prior electrophysiology study in 2010 at an outlying facility, documenting an anteroseptal accessory pathway near the His bundle along with an unsuccessful attempt at radiofrequency ablation at that time. No supraventricular tachycardia was induced at that previous study. The surface electrocardiogram (ECG), at this time, was consistent with the anteroseptal WPW pattern. The patient now presented with a complaint of intermittent palpitations with no definitive trigger. He also described a recent syncopal episode while walking inside his home. His physical exam and all lab work were within normal limits for his age. He underwent a repeat electrophysiology (EP) study where the baseline PR interval was 62 milliseconds and the QRS duration was 172 milliseconds in a pre-excited pattern. There was found to be an antegrade-only conducting accessory pathway at the anteroseptal region near the His bundle. Antegrade AVRT was induced with a single ventricular extra stimulus while on 2 mcg/min isoproterenol. Cryoablation was performed in a position slightly posterior to the His bundle, which successfully resolved the accessory pathway conduction. First-degree atrioventricular (AV) block was noted in the sinus rhythm with a PR interval of 226 milliseconds post-cryoablation. There was no recurrence of accessory pathway conduction on follow-up ECG 24 hours post-cryoablation. Antidromic AVRT is a very rare finding in WPW syndrome during an EP study. Catheter ablation is the treatment of choice for patients who have symptomatic WPW syndrome. Catheter ablation can be especially challenging when the accessory pathway is in close proximity to the normal conduction pathways. The prognostic significance of inducible antidromic AVRT is controversial in asymptomatic patients and limited data indicate it may be a poor prognostic sign in children. In adults, the prognostic significance is not well-established. Cryoablation is an option for the ablation of accessory pathways that are close to the normal conduction pathways. "Cryomapping" is designed to have precise ablation and to reassure the absence of complications.

Unintentional Injuries and Violence among Adults in Northern Jordan: A Hospital-Based Retrospective Study.

Injuries (unintentional and intentional) are the main cause of death and disability worldwide, including Jordan. The main purpose of this hospital-based retrospective study was to identify characteristics, causes, and risk factors of unintentional injuries and violence among all adult patients who approached the Accidents and Emergency department because of injury in Northern Jordan. Data were collected retrospectively from four major hospitals from January 2008 to January 2013. A total of 2425 Jordanian individuals who accessed and were treated by the four hospitals were included in this study. The findings show that the majority of patients who approached the Accidents and Emergency departments in the four hospitals were males (n = 2044, 87.16%) versus females (n = 301, 12.8%). Violence was the most common reason of injury (70.66%), followed by road traffic crashes (23.21%). The most common anatomical locations of reported injuries were the head (38.74%), followed by abdomen/pelvis and lower back, among males and females (9.93%). Violence had a high significant effect on the site of injuries. Patients who had been injured to the head because of a stab wound or fighting were substantially over-involved in head injuries, with injury rates 3.88 and 7.51 times higher than those who had been injured to the head due to gunshot, respectively. Even patients who had been injured to the head because of assault show much higher involvement in injury risk than non-assault patients (Odds Ratio = 8.46). These findings highlight the need for a large national study to confirm the findings. It also draws attention to the importance of public awareness and to special injury prevention programs that not only focus on saving lives and lessening the number of injuries, illnesses, and fatalities, but also to limit the social and economic burden of injury among adults in Northern Jordan.