Efficacy and safety of EUS-directed transgastric ERCP (EDGE) versus laparoscopic-assisted ERCP: A systematic review and meta-analysis.

The altered anatomy in Roux-en-Y gastric bypass (RYGB) makes conventional endoscopic retrograde cholangiopancreatography (ERCP) a technically challenging procedure. EUS-directed transgastric ERCP (EDGE) and laparoscopic-assisted ERCP (LA-ERCP) are alternative modalities used with comparable efficacy and adverse events in such patients. We conducted a meta-analysis comparing EDGE and LA-ERCP to assess the efficacy and safety in patients with RYGB. We conducted a comprehensive literature search from inception to July 7, 2022, on MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science databases using the core concepts of EDGE and LA-ERCP. We excluded case reports, case series (<10 patients), and review articles. Relative risk (RR) was calculated when comparing dichotomous variables, whereas mean difference was calculated for continuous outcomes. A 95% confidence interval (CI) and P values (<0.05 considered significant) were also generated. The search strategy yielded a total of 55 articles. We finalized 4 studies with total 192 patients (75 EDGE and 117 LA-ERCP). The rates of technical success were not significantly different for LA-ERCP and EDGE (RR, 0.994; 95% CI, 0.939-1.051; P = 0.830, I 2 = 0%) Similarly, no difference in adverse events was noted between the 2 groups (RR, 1.216; 95% CI, 0.561-2.634; P = 0.620, I 2 = 10.67%). Shorter procedure time was noted for EDGE compared with the LA-ERCP group (mean difference, 91.53 min; 95% CI, 69.911-113.157 min; P < 0.001, I 2 = 8.32%). EDGE and LA-ERCP are comparable in terms of efficacy and safety. In addition, EDGE has overall lower procedural time. Our study suggests that EDGE should be considered as a first-line therapy if expertise available.

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.

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.

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.

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.

Esophagopericardial Fistula After Esophagectomy.

Esophagectomy is the mainstay surgical treatment for esophageal carcinoma. The operation can be complicated by an anastomotic stricture, anastomotic leak, recurrent laryngeal nerve injury, conduit ischemia, and chylothorax. Rarely, esophagectomy can be complicated by fistula formation between the gastrointestinal tract and the nearby structures. We describe a case of esophagopericardial fistula after esophagectomy. A 50-year-old man presented to the emergency room with a chest pain of two-week duration associated with sweating, chills, and poor appetite. He was diagnosed with stage III esophageal adenocarcinoma four months ago. He had received neoadjuvant chemotherapy followed by distal esophagectomy, partial gastrectomy, and placement of a jejunostomy tube one month before presentation. Cardiovascular examination was significant for jugular venous distention and distant heart sounds. Chest CT angiography showed pneumomediastinum concerning for anastomotic leak. Esophagram finally confirmed an esophagopericardial fistula. A drain was placed into the pericardial space followed by emergent esophageal stent placement. Eventually, he underwent a cervical esophagostomy and placement of a jejunostomy tube. The patient was later discharged home in a stable condition. In conclusion, esophagopericardial fistula is a rare adverse event of esophagectomy. Esophageal stenting could be useful as a temporary or definite treatment.

Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis: a systematic review and meta-analysis.

BACKGROUND: The role of anticoagulation in treating non-malignant portal vein (PV) thrombosis (PVT) in patients with liver cirrhosis remains unclear. In our meta-analysis, we aimed to evaluate the efficacy and safety of anticoagulation for the treatment of non-malignant PVT in these patients. METHODS: We conducted a meta-analysis to estimate the effects of anticoagulation on non-malignant PVT in patients with liver cirrhosis. We assessed the rates of PV recanalization, variceal bleeding, and any bleeding. RESULTS: We included 9 observational studies which involved 474 patients. The rate of PV recanalization was significantly higher in patients who received anticoagulation compared to those who did not: 65.2% vs. 25.2%; relative risk (RR) 2.31, 95% confidence interval (CI) 1.80-2.96; P<0.00001. Variceal bleeding was significantly lower in patients who received anticoagulation: 0.1% vs. 18.5%; RR 0.15, 95%CI 0.04-0.55; P=0.004. Any bleeding was similar between patients who received anticoagulation and those who did not: 10.3% vs. 22.7%; RR 0.43, 95%CI 0.09-1.99; P=0.28. CONCLUSIONS: Anticoagulation use increased the rate of PV recanalization in cirrhotic patients with non-malignant PVT. Anticoagulation decreased the rate of variceal bleeding and did not increase the rate of any bleeding.

Efficacy of Endocuff Vision compared to first-generation Endocuff in adenoma detection rate and polyp detection rate in high-definition colonoscopy: a systematic review and network meta-analysis.

Background and study aims Recently, the newer Endocuff Vision (ECV) has been evaluated for improving colonoscopy outcome metrics such as adenoma detection rate (ADR) and polyp detection rate (PDR). Due to lack of direct comparative studies between ECV and original Endocuff (ECU), we performed a systematic review and network meta-analysis to evaluate these outcomes. Methods The following databases were searched: PubMed, Embase, Cochrane, and Web of Sciences to include randomized controlled trials (RCTs) comparing ECV or ECU colonoscopy to high-definition (HD) colonoscopy. Direct as well as network meta-analyses comparing ADR and PDR were performed using a random effects model. Relative-risk (RR) with 95 % confidence interval (CI) was calculated. Results A total of 12 RCTs with 8638 patients were included in the final analysis. On direct meta-analysis, ECV did not demonstrate statistically improved ADR compared to HD colonoscopy (RR: 1.12, 95 % CI 0.99-1.27). A clinically and statistically improved PDR was noted for ECV compared to HD (RR: 1.15, 95 % CI 1.03-1.28) and ECU compared to HD (RR: 1.26, 95 % CI 1.09-1.46) as well as improved ADR (RR: 1.22, 95 % CI 1.05-1.43) was observed for ECU colonoscopy when compared to HD colonoscopy. These results were also consistent on network meta-analysis. Lower overall complication rates (RR: 0.14, 95 % CI 0.02-0.84) and particularly lacerations/erosions (RR: 0.11, 95 % CI 0.02-0.70) were noted with ECV compared to ECU colonoscopy. Conclusions Although safe, the newer ECV did not significantly improve ADR compared to ECU and HD colonoscopy. Further device modification is needed to increase the overall ADR and PDR.

Do Water-aided Techniques Improve Serrated Polyp Detection Rate During Colonoscopy?: A Systematic Review With Meta-Analysis.

BACKGROUND AND STUDY AIMS: The utility of water-aided techniques (WT): water exchange (WE) and water immersion (WI) have been studied extensively in the literature for improving colonoscopy outcome metrics such as adenoma detection rate. Serrated polyps owing to their location and appearance have a high miss rate. The authors performed a systematic review and meta-analysis of studies comparing WT with the standard gas-assisted (GA) method to determine if there was any impact on serrated polyp detection rate (SPDR) and sessile serrated polyp detection rate. METHODS: The following databases were queried for this systematic review: Medline, EMBASE, Cochrane Library, CINAHL, and Web of Sciences. The authors only included randomized controlled trials (RCTs). The primary outcome was SPDR and secondary outcomes were sessile serrated polyp detection rate and cecal intubation rate. Risk ratios (RRs) were calculated for each outcome. A P-value <0.05 was considered to be statistically significant. RESULTS: A total of 4 RCTs (5 arms) with 5306 patients (2571 in the GA group and 2735 in the WT group) were included. The SPDR was significantly increased for the WT group compared with GA (6.1% vs. 3.8%; RR, 1.63; 95% confidence interval, 1.24-2.13; P<0.001; I2=22.7%). A subgroup analysis for WE technique also demonstrated improved SPDR compared with the GA method (4.9% vs. 3.2%; RR, 1.57; 95% confidence interval, 1.15-2.14; P=0.004; I2=6.1%). CONCLUSIONS: WT, particularly, the WE method results in improved SPDR. This technique should be encouraged in a clinical setting to detect these polyps to prevent interval colorectal cancer.

Does timing of endoscopy affect outcomes in patients with upper gastrointestinal bleeding: a systematic review and meta-analysis.

BACKGROUND AND AIMS: The timing of esophagogastroduodenoscopy (EGD) for the management of upper gastrointestinal bleeding (UGIB) remains controversial. Early EGD (E-EGD) (within 24 h of presentation) has been compared to late EGD (L-EGD) (after 24 h) in numerous studies with conflicting results. The previous systematic review included three randomized controlled trials (RCTs); however, the cutoff time for performing EGD was arbitrary. We performed an updated systematic review and meta-analysis of the studies comparing the outcomes of E-EGD and L-EGD group. METHODS: A comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was undertaken to include both RCTs and cohort studies. Primary outcomes including overall mortality and secondary outcomes (recurrent bleeding, need for transfusion, and length of stay) were compared. Risk ratios and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated. RESULTS: A total of 13 observational studies (with over 1.8 million patients) were included in the final analysis. No significant difference in overall mortality (risk ratio: 0.97; CI, 0.74-1.27), recurrent bleeding (risk ratio: 1.12; CI, 0.62-2.00), and length of stay (SMD: -0.07, CI, -0.31 to 0.18) was observed for E-EGD group compared to L-EGD group. The possibility of endoscopic intervention was higher in E-EGD group (risk ratio: 1.70, CI, 1.28-2.27). Consistent results were obtained for subgroup analysis of studies with 100% nonvariceal bleed (NVB) patient (risk ratio: 1.12; CI, 0.84-1.50). CONCLUSION: Given the outcomes and limitations, our meta-analysis did not demonstrate clear benefit of performing EGD within 24 h of presentation for UGIB (particularly NVB).

Eosinophilic Esophagitis After an Allegra-D Bolus: A Case Report.

Eosinophilic esophagitis (EoE) is an immune-mediated disorder that may be related to exposure to additive chemicals in crops, air pollutants, or supplements found within livestock. Co-occurring allergic or atopic diseases including atopic dermatitis, food allergies, and asthma are also commonly seen in 70% of cases and help guide diagnosis. Diagnosis of EoE requires eosinophilic infiltration greater than 15 eosinophils per high power field (HPF) with endoscopic evidence of abnormal esophageal changes. Here, we discuss a rare presentation of food bolus impaction secondary to EoE after ingestion of a nasal decongestant and antihistamine pill that has previously never been described in the literature. A 22-year-old male with no significant past medical history presented to the emergency department (ED) with a chief complaint of a sudden onset respiratory distress, regurgitation of clear oral secretions, and globus sensation post ingestion of a fexofenadine-pseudoephedrine tablet. Prior to intake of the capsule, the patient was consuming liquids and solids appropriately. The patient was afebrile, hypertensive at 172/114, and found to have a normal heart rate of 88 bpm and a respiration rate of 18 breaths per minute. An esophagogastroduodenoscopy (EGD) was performed, which revealed a fexofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus. The foreign body was successfully removed using raptor forceps. Further visualization demonstrated trachealization of the esophagus and furrowing and severe narrowing (< 10mm), which raised suspicion for EoE. Proximal biopsy indicated 16 intraepithelial eosinophils per HPF within the squamous epithelium, likely compatible with EoE. The patient tolerated the procedure well and was discharged on an eight-week course of proton-pump inhibitors. EoE is defined as an immune-mediated esophageal disease characterized histologically by eosinophil-predominant inflammation. Our patient was reported to have up to 30 eosinophils per HPF from the proximal esophageal biopsy, which satisfies the requirements for an EoE diagnosis. Based on the current literature review, there have been no other reported cases of symptomatic food bolus impaction secondary to EoE after ingestion of antihistamines.

Over-the-Scope Clip Closure of an Esophageal-Pleural Fistula Secondary to Esophageal Stent Placement: A Case Report.

An esophageal fistula is a pathological connection between the esophagus and another structure. The most common treatment for an esophageal fistula is airway stenting. However, several case series have demonstrated the superiority of the over-the-scope clip (OTSC) system for fistula closure. We report a case requiring multiple stent/OTSC placements in an esophageal-pleural fistula (EPF) due to underlying malignancy. A 57-year-old male with stage IV esophageal cancer with an esophageal stent presented with three days of back pain and shortness of breath. A gastrografin was performed and showed a fistula at the proximal aspect of the pre-existing esophageal stent. A self-expandable metallic stent (SEMS) was utilized to bridge the fistula to the pre-existing esophageal stent. An esophagram two days later revealed extravasation and continuous esophageal leak. OTSC was then deployed at the fistula. A SEMS was also implanted through the patient's pre-existing stent. Endoscopy showed persistent esophageal perforation. The initial OTSC and SEMS combination was removed. After removal, a second OTSC was placed over the fistula, allowing for complete suction of the fistula into the OTSC clip cap. We followed this by deploying another SEMS through the pre-existing stent and clipping them together. The proximal end of this new stent fully covered the fistula, creating a complete seal. This case is notable in that successful EPF closure secondary to existing esophageal stent erosion was achieved by utilizing a properly positioned OTSC with stent-within-stent combination management.

Rates and Predictors of 30-Day Readmissions in Patients Undergoing Bariatric Surgery in the US: a Nationwide Study.

BACKGROUND: Among various therapeutic options for morbid obesity, bariatric surgery (BS) is now considered one of the most effective methods of weight loss. We decided to perform an analysis to look at 30-day all-cause readmission and independent predictors of readmission in patients undergoing BS. METHODS: We queried the 2017 Nationwide Readmission Database (NRD) using ICD-10-CM diagnosis codes to identify all adult patients who underwent BS from January 1 to November 30, 2017. Outcomes assessed were 30-day readmission rates, mortality, length of stay (LOS) and hospitalization costs, and independent predictors of readmission. RESULTS: A total of 182,848 adult patients underwent BS during hospitalization in 2017, with in-hospital mortality rate of 0.52% (951). Of the patients discharged, 4.99% (9088) patients were readmitted within 30 days. The most common primary diagnosis at readmission was "Other complications of other bariatric surgery". When compared with index admission, readmitted patients had higher in-hospital mortality (0.52% vs 2.06%, p < 0.01), increased mean LOS (2.94 days vs 5.94 days, p < 0.01) but lower mean hospitalization charges ($67,763 vs $66,065, p < 0.01). Increasing age (HR 1.01, 95% CI: 1.006-1.014, p < 0.01), longer LOS (HR 1.01, 95% CI: 1.008-1.014, p < 0.01), higher comorbidity score (HR 1.15, 95% CI: 1.12-1.18, p < 0.01), CHF (HR 1.19, 95% CI: 1.01-1.42, p < 0.05), and AKI (HR 1.64, 95% CI: 1.34-2.02, p < 0.01) were independently associated with increased likelihood of 30-day readmission. CONCLUSION: This study shows that almost 5% patients undergoing bariatric surgery are readmitted within 30 days of discharge in the US. Further studies are needed to assess the high-risk populations to understand the reasons predisposing to early readmission.

A Rare Complication of Ileus Following Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis: A Case Report.

Pancreatic cancer patients experience debilitating pain, which makes pain management an integral part of the treatment plan. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-guided CPN) is an alternative palliative therapy for patients with pain due to pancreatic cancer. We report a patient who developed paralytic ileus after undergoing EUS-guided CPN.  A 77-year-old male patient presented with nausea, vomiting, and abdominal pain of one-day duration. He was diagnosed with stage IV pancreatic adenocarcinoma three weeks prior to presentation for which he underwent EUS-guided CPN. He had a 30-pack-year smoking history and quit 31 years ago. He reported moderate alcohol use and denied illicit drug use. In the emergency department, vital signs demonstrated normal blood pressure, heart rate, respiratory rate, and temperature. Abdominal exam was significant for minimal epigastric tenderness without guarding or rebound. Complete blood count (CBC), basic metabolic panel (BMP), and liver function tests were unremarkable. Computed tomography (CT) scan of the abdomen showed significant gastric distension. Esophagogastroduodenoscopy (EGD) showed large amounts of fluids within the gastric fundus and body. Upper gastrointestinal series showed delayed gastric emptying of the contrast, but contrast was seen in the third part of the duodenum and jejunum. Push enteroscopy showed no obstruction or mucosal abnormalities in the third or fourth parts of the duodenum. Small bowel obstruction was ruled out, and the diagnosis of ileus was made. The patient received ondansetron and polyethylene glycol as needed, and his diet was advanced slowly. His symptoms improved over the course of a few days, and he experienced a return of normal bowel activity. He eventually tolerated a regular diet and was discharged home in a stable condition. Although EUS-guided CPN is a safe procedure, the procedure resulted in an unexpected ileus that has rarely been reported in the literature. Future studies with large sample sizes are recommended to capture the occurrence of the rare side effects of EUS-guided CPN.

Incidental Ascending Colon Ganglioneuroma in the Setting of Hematochezia.

Ganglioneuromas are slow-growing hamartomatous tumors that are rarely found in the colon. There are three subtypes of ganglioneuromas: polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. They are differentiated depending on their endoscopic and histological characteristics. Patients with colonic ganglioneuroma may present with nonspecific symptoms; however, they are usually asymptomatic. We present a case of hematochezia, where an ascending colon ganglioneuroma was found incidentally on diagnostic colonoscopy. We will explain how to distinguish the three subtypes of ganglioneuroma on colonoscopy and will mention the genetic disorders associated with them. We will also discuss the treatment of ganglioneuromas.

Safety of bariatric surgery in patients with inflammatory bowel disease: A systematic review and meta-analysis.

The efficacy of bariatric surgery in achieving weight loss and preventing long-term comorbidities such as cardiovascular diseases, diabetes mellitus and osteoarthritis is well established. Data regarding safety of bariatric surgery in patients with inflammatory bowel disease (IBD) is scarce. We attempted a systematic review and meta-analysis to evaluate the complications following bariatric surgery in patients with IBD. The primary outcomes evaluated were wound infection, Clavien-Dindo grade > II complications and IBD exacerbation (within 1 year). Secondary outcomes evaluated included overall mortality, stricture, small bowel obstruction, acute kidney injury (AKI) and thromboembolism. Pooled outcomes (event rate) with 95% confidence interval (CI) were calculated using random effects model. A total of 14 studies (all observational) with 2608 patients were included. The rates of primary outcomes were: wound infection (4.1%, 95% CI: 0.9-7.2), Clavien-Dindo grade > II complications (2.0%, 95%: CI 0.6-3.5) and IBD exacerbation (4.3%, 95% CI: 0.7-7.9). The pooled rate for other outcomes was: mortality 0.1%, stricture 6.5%, small bowel obstruction 6.7%, AKI 2.2% and thromboembolism 0.1%. Bariatric surgery is relatively safe in patients with IBD and should be pursued to reduce comorbidities associated with obesity. Future comparative studies are needed to further assess the safety of bariatric surgery in population with and without IBD.

Comparing endoscopic interventions to improve serrated adenoma detection rates during colonoscopy: a systematic review and network meta-analysis of randomized controlled trials.

OBJECTIVE: Serrated lesions (sessile serrated adenomas/polyps and traditional serrated adenomas) owing to their subtle appearance and proximal location have a high miss rate. The objective of this study is to compare all the available endoscopic interventions for improving serrated adenoma detection rate (SADR) through a network meta-analysis. METHODS: We conducted a systematic review of the available literature (PubMed, Embase, Cochrane and WoS) from inception to 29 November 2019 to identify all the relevant randomized controlled trials. A total of 28 trials with 22 830 patients were included. The studies compared the efficacy of add-on devices (endocap, endocuff, endocuff vision, G-EYE, endorings, AmplifEYE), electronic chromoendoscopy (linked-color imaging, blue laser imaging, narrow band imaging), dye-based chromoendoscopy, full-spectrum endoscopy (FUSE) and water-based techniques (WBT) with each other or high-definition colonoscopy. Both pairwise and network meta-analysis was conducted using the random-effects model. Risk ratios (RR) with 95% confidence intervals (CI) and P-values were calculated. RESULTS: Direct meta-analysis demonstrated superiority for WBT (RR: 1.41, CI: 1.01-1.98), add-on devices (RR: 1.53, CI: 1.13-2.08), narrow band imaging (RR: 1.93, CI: 1.12-3.32) and endocuff vision (RR: 1.87, CI: 1.13-3.11) compared to high-definition colonoscopy. The results were consistent on network meta-analysis with chromoendoscopy as an additional modality for improving SADR (RR: 1.74, CI: 1.03-2.93). CONCLUSION: In a network meta-analysis, add-on devices (particularly endocuff vision), narrow band imaging, WBT and chromoendoscopy were comparable to each other and improved SADR compared to high-definition colonoscopy.

Trends and outcomes of fungal infections in hospitalized patients of inflammatory bowel disease: a nationwide analysis.

BACKGROUND: Immunosuppressive therapy is being increasingly used in the management of inflammatory bowel disease (IBD) which comprises of ulcerative colitis (UC) and Crohn's disease (CD). Patients on immunosuppressive therapy are at increased risk of developing opportunistic fungal infections. We conducted this analysis to describe the epidemiology of opportunistic fungal infections in this cohort. METHODS: We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of IBD (UC and Crohn's disease) & Fungal infections (Histoplasmosis, Pneumocystosis, Cryptococcosis, Aspergillosis, Blastomycosis, candidiasis, Coccidioidomycosis) as primary or secondary diagnosis via ICD 9 codes during the period from 2002-2014. RESULTS: In UC, the incidence of all fungal infections was more in age above 50 (except for pneumoconiosis) male gender (except Candidiasis) and in Caucasians. In CD, the incidence was more in age above 50 (except Pneumocystosis, Blastomycosis & Coccidioidomycosis), female gender (except Histoplasmosis, Pneumocystosis & Cryptococcosis) and in Caucasians. Histoplasmosis and Blastomycosis were more prevalent in Midwest, Cryptococcosis and Candidiasis in South, Coccidioidomycosis in west in both UC and CD. Age above 50, south region, HIV, Congestive heart failure, underlying malignancies, diabetes mellitus with complications, chronic pulmonary disease, anemia, rheumatoid arthritis, collagen vascular disease, pulmonary circulation disorders, weight loss were significant predictors of fungal infections in IBD. The yearly trend showed a consistent small rise in incidence, and the mortality dropped till 2006 to peak again in 2008 with a subsequent decline. CONCLUSIONS: Our study is the first one to describe the basic demographics features and characteristics of opportunistic fungal infections in hospitalized patients with IBD. The yearly incidence of fungal infections did not show a significant rise. The mortality increased between 2006-2008 and a significant difference remains between IBD patients with and without fungal infections. One explanation of rise in mortality but a consistent incidence could be due to the use of biologics that did not increase but compromised the ability of IBD patients to fight opportunistic fungal infections.

Impact of propofol sedation versus opioid/benzodiazepine sedation on colonoscopy outcomes: a systematic review with meta-analysis.

Background and study aims Choice of sedation (propofol vs opioid/benzodiazepine) has been studied in the literature and has shown variable outcomes. The majority of recent studies have evaluated propofol sedation (PS) versus opioids, benzodiazepines, or a combination of both. We performed a systematic review and meta-analysis of studies comparing PS to other sedation methods to assess the impact on colonoscopy outcomes. Methods Multiple databases were searched and studies of interest were extracted. Primary outcome of the study was adenoma detection rate (ADR) and secondary outcomes included polyp detection rate (PDR), advanced adenoma detection rate (AADR), and cecal intubation rate (CIR). Results A total of 11 studies met the inclusion criteria with a total of 177,016 patients (148,753 and 28,263 in the opioids/benzodiazepine group and PS group, respectively). Overall, ADR (RR: 1.07, 95 % CI 0.99-1.15), PDR (RR: 1.01, 95 % CI 0.93-1.10), and AADR (RR: 1.17, 95 % CI 0.92-1.48) did not improve with the use of PS. The CIR was slightly higher for propofol sedation group (RR 1.02, 95 % CI 1.00-1.03). Conclusion Based on our analysis, PS and opioid/benzodiazepine sedation seem to have comparable ADR. Our results do not favor use of a particular sedation method and the choice of sedation should be individualized based on patient preference, risk factors and resource availability.