Endoscopic Ultrasound-Guided vs Endoscopic Retrograde Cholangiopancreatography-Guided Biliary Drainage as Primary Approach to Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary drainage in malignant distal biliary obstruction (MDBO). This meta-analysis of randomized controlled trials (RCTs) aims to compare the outcomes of these 2 approaches. METHODS: Electronic databases from January 2005 through December 2023 were searched for RCTs comparing outcomes of EUS-BD and ERCP for treating MDBO. Pooled proportions, risk ratio (RR), and odds ratio were calculated using random-effects models. RESULTS: Five RCTs comprising 519 patients were included in the final analysis. The pooled RR for overall technical success with EUS-BD compared with ERCP was 1.05 (95% confidence interval [CI] = 0.96-1.16, P = 0.246, I2 = 61%) and for clinical success was 0.99 (95% CI = 0.95-1.04, P = 0.850, I2 = 0%). The pooled rate of procedure-related pancreatitis was 7.20% (95% CI = 3.60-13.80, I2 = 34%) in the ERCP group compared with zero in the EUS-BD group. The pooled RR for stent dysfunction with EUS-BD compared with ERCP was 0.48 (95% CI = 0.28-0.83, P = 0.008, I2 = 7%). The weighted mean procedure time was 13.43 (SD = 10.12) minutes for EUS-BD compared with 21.06 (SD = 6.64) minutes for ERCP. The mean stent patency was 194.11 (SD = 52.12) days in the EUS-BD group and 187 (SD = 60.70) days in the ERCP group. DISCUSSION: EUS-BD is an efficient and safe alternative to ERCP in MDBO. An almost nonexistent risk of procedure-related pancreatitis, lower procedure time, and ease of use make this an attractive primary approach to biliary decompression in centers with expertise.

Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis.

BACKGROUND AND STUDY AIMS : Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique. METHODS : Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events. RESULTS : Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08). CONCLUSIONS : Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.

Utility of Cyst Fluid Carcinoembryonic Antigen in Differentiating Mucinous and Non-mucinous Pancreatic Cysts: An Updated Meta-Analysis.

BACKGROUND: Mucinous pancreatic cysts are considered premalignant and managed differently compared to benign pancreatic cystic lesions. The aim of this updated meta-analysis is to assess the diagnostic accuracy of cyst carcinoembryonic antigen (CEA) in differentiating between mucinous and non-mucinous pancreatic cysts. METHODS: Studies comparing the diagnostic accuracy of CEA (cutoff level of 192 ng/mL) in differentiating between mucinous and non-mucinous pancreatic cysts were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooled estimates of diagnostic precision were calculated using random and fixed effects models. RESULTS: Initial search identified 526 reference articles, of these 34 relevant articles were selected and reviewed. Data were extracted from 15 studies (n = 2063) which met the inclusion criteria. The pancreatic cystic fluid CEA level at a 192 ng/mL cutoff value had pooled specificity of 88.6% (95% CI 85.9-90.9) and pooled sensitivity was found to be 60.4% (95% CI 57.7-62.9). The pooled positive likelihood ratio was 4.5 (95% CI 2.9-6.9) and the pooled negative likelihood ratio was 0.45 (95% CI 0.38-0.52). The pooled diagnostic odds ratio, the odds of having mucinous cyst with elevated CEA, was 11.4 (95% CI 6.9-18.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSIONS: This meta-analysis suggests that the cyst fluid CEA level at a 192 ng/mL cutoff value is highly specific in the diagnosis of mucinous cystic lesions with reasonable sensitivity.

Are self-expandable metal stents superior to plastic stents in palliating malignant distal biliary strictures? A meta-analysis and systematic review.

BACKGROUND: Palliation for inoperable malignant distal biliary strictures can be achieved with self-expandable metal stents (SEMS) and plastic stents (PS). This is a meta-analysis to compare PS and SEMS. The aim of the study is to compare clinical outcomes in patients with SEMS and PS. METHODS: Study selection criteria were studied using SEMS and PS for palliation in patients with malignant distal biliary stricture. For data collection and extraction, articles were searched in Ovid journals, Medline, Cochrane database, and Pubmed. Pooled proportions were calculated using both Mantel-Haenszel method and DerSimonian Laird method for statistical analysis. RESULTS: Initial search identified 1376 reference articles, of which 112 were selected and11 studies (N = 947) were included in this analysis. Pooled analysis showed SEMS patency to be 167.7days (95% CI = 159.2-176.3) compared to 73.3days (95% CI = 69.8-76.9) in PS. SEMS have lower odds of occlusion when compared to PS with an odds ratio of 0.48 (95% CI = 0.34-0.67). SEMS has a lower odds of cholangitis compared to SP, with an odds ratio of 0.46 (95% CI = 0.30-0.69). CONCLUSION: SEMS seem to be superior to PS with better patency periods and survival duration. SEMS have lower occlusion rates, re-intervention rates, and cholangitis.

Low-residue versus clear liquid diet before colonoscopy: a meta-analysis of randomized, controlled trials.

BACKGROUND AND AIMS: Colonoscopy is extremely important for the identification and removal of precancerous polyps. Bowel preparation before colonoscopy is essential for adequate visualization. Traditionally, patients have been instructed to consume only clear liquids the day before a colonoscopy. However, recent studies have suggested using a low-residue diet, with varying results. We evaluated the outcomes of patients undergoing colonoscopy who consumed a clear liquid diet (CLD) versus low-residue diet (LRD) on the day before colonoscopy by a meta-analysis. METHODS: Scopus, PubMed/MEDLINE, Cochrane databases, and CINAHL were searched (February 2015). Studies involving adult patients undergoing colonoscopy examination and comparing LRD with CLD on the day before colonoscopy were included. The analysis was conducted by using the Mantel-Haenszel or DerSimonian and Laird models with the odds ratio (OR) to assess adequate bowel preparations, tolerability, willingness to repeat diet and preparation, and adverse effects. RESULTS: Nine studies (1686 patients) were included. Patients consuming an LRD compared with a CLD demonstrated significantly higher odds of tolerability (OR 1.92; 95% CI, 1.36-2.70; P < .01) and willingness to repeat preparation (OR 1.86; 95% CI, 1.34-2.59; P < .01) with no differences in adequate bowel preparations (OR 1.21; 95% CI, 0.64-2.28; P = .58) or adverse effects (OR 0.88; 95% CI, 0.58-1.35; P = .57). CONCLUSION: An LRD before colonoscopy resulted in improved tolerability by patients and willingness to repeat preparation with no differences in preparation quality and adverse effects.

Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review.

BACKGROUND: In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by restoration of biliary flow prior to operation. This is a meta-analysis to pool the evidence and assess the utility of PBD in patients with malignant obstructive jaundice. The primary outcome is comparing mortality outcomes in patients with malignant obstructive jaundice undergoing direct surgery (DS) versus PBD. The secondary outcomes include major adverse events and length of hospital stay in both the groups. METHODS: Studies using PBD in patients with malignant obstructive jaundice were included in this study. For the data collection and extraction, articles were searched in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, etc. Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model). RESULTS: Initial search identified 2230 reference articles, of which 204 were selected and reviewed. Twenty-six studies (N = 3532) for PBD in malignant obstructive jaundice which met the inclusion criteria were included in this analysis. The odds ratio for mortality in PBD group versus DS group was 0.96 (95 % CI = 0.71 to 1.29). Pooled number of major adverse effects was lower in the PBD group at 10.40 (95 % CI = 9.96 to 10.83) compared to 15.56 (95 % CI = 15.06 to 16.05) in the DS group. Subgroup analysis comparing internal PBD to DS group showed lower odds for major adverse events (odds ratio, 0.48 with 95 % CI = 0.32 to 0.74). CONCLUSIONS: In patients with malignant biliary jaundice requiring surgery, PBD group had significantly less major adverse effects than DS group. Length of hospital stay and mortality rate were comparable in both the groups.

Miralax with gatorade for bowel preparation: a meta-analysis of randomized controlled trials.

OBJECTIVES: Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax-Gatorade (M-G) vs. PEG for bowel preparation before colonoscopy. METHODS: Multiple databases were searched (January 2014). RCTs on adults comparing M-G (238-255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8-4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models. RESULTS: Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M-G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43-0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88-10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M-G vs. split-dose PEG. CONCLUSIONS: M-G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M-G for bowel preparation before colonoscopy.

Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding.

BACKGROUND: Multiple studies have demonstrated that feeding ≤4 hours after placement of a percutaneous endoscopic gastrostomy (PEG) tube is a reasonable option. Many physicians, however, continue to delay feedings until the next day or 24 hours; therefore, we evaluated the safety and effect of early feeding (≤4 hours) after PEG placement in our tertiary care center. METHODS: A retrospective study of 444 patients who underwent PEG between June 2006 and December 2011 was performed. Early feeding was defined as feeding ≤4 hours and delayed feeding was defined as feeding >4 hours. Statistical analysis was performed using the Fisher exact test and the Student t test. RESULTS: A total of 444 patients underwent PEG between June 2006 and December 2011. A majority of PEGs were performed on inpatients by gastroenterologists. The mean time of feeding after PEG was 3.2 ± 0.9 hours for the early group (n = 197) and 17.0 ± 10.0 hours for the delayed group (n = 247). No statistically significant differences were noted between the early (≤4 hours) feedings versus the delayed (>4 hours) feedings for overall morality within 30 days (P = 0.72) and overall complications (P = 1.00). Furthermore, no statistically significant differences were noted between early versus delayed feeding for 24-hour mortality (P = 1.00), 24- to 72-hour mortality (P = 0.20), and 3-30 days mortality (P = 0.86). For each complication, there were no statistically significant differences noted between the two groups for wound infection (P = 0.52), melena (P = 0.26), vomiting (P = 0.42), leakage (P = 0.41), stomatitis (P = 0.13), aspiration pneumonia (P =1.00), and other complications (P = 0.47). CONCLUSIONS: Feeding ≤4 hours after PEG appears to be as safe as delayed feeding. Based on this study and the literature, strong consideration for the majority of patients should be undertaken to begin feeding within 4 hours after PEG.

Endoscopic ultrasound-guided lumen-apposing metal stent with or without coaxial plastic stent for pancreatic fluid collections: a systematic review and meta-analysis comparing safety and efficacy.

Background: Endoscopic ultrasound (EUS)-guided lumen-apposing metal stents (LAMS) are preferred for draining symptomatic large pancreatic fluid collections (PFCs). A concurrent coaxial double-pigtail plastic stent (DPPS) is proposed to reduce adverse events associated with LAMS. We aimed to perform a comparative outcome analysis of LAMS with or without DPPS for PFCs. Methods: Electronic databases from January 2005 through July 2023 were searched for studies comparing the use of LAMS with or without DPPS for PFCs. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results: After reviewing 1780 studies, we extracted data from 6 studies comprising 348 patients. The weighted odds of overall technical success, using LAMS plus DPPS compared to LAMS alone, were 0.53 (95% confidence interval [CI] 0.15-1.83), and the odds of clinical success were 1.10 (95%CI 0.59-2.05). The weighted odds of total adverse events with LAMS compared to LAMS plus DPPS were 2.21 (95%CI 1.37-3.59). Analysis of individual adverse events showed that the odds of stent occlusion when LAMS alone was used compared to LAMS plus DPPS was 2.36 (95%CI 1.12-4.98). The odds of bleeding were 1.84 (95%CI 0.77-4.38), and the odds of stent migration 0.95 (95%CI 0.40-2.23). Conclusions: EUS-guided LAMS placement is the current standard of care for managing symptomatic large PFCs. Concurrent use of coaxial DPPS can mitigate the overall adverse events observed with LAMS, while maintaining similar technical and clinical success.

Endoscopy after acute myocardial infarction: an evaluation of safety.

OBJECTIVES: Upper gastrointestinal bleeding in the setting of acute myocardial infarction (MI) has substantial morbidity and mortality. Several studies have been performed on the safety of esophagogastroduodenoscopy (EGD) after MI; however, these studies vary in definitions and results. We evaluated the safety and effect of EGD in patients with acute MI in a tertiary center. METHODS: A retrospective, single tertiary-care center study was undertaken of 87 patients who underwent EGD within 30 days of an acute MI between January 2001 and March 2012. Type of MI (ST segment elevation MI [STEMI] and non-ST segment elevation MI [NSTEMI]), peak troponin I, time from MI to EGD, Acute Physiology and Chronic Health Evaluation (APACHE) II score at EGD, cardiac catheterization before EGD, and medical complications within 24 hours of EGD were noted. Medical complications were defined as major complications (death, life-threatening arrhythmias) and minor complications (chest pain, abnormal vital signs, or minor arrhythmias). RESULTS: Eighty-seven patients underwent EGD within 30 days of having an MI. No major complications were observed. Minor complications occurred in 27 of 87 patients (31.0%), including mild hypotension, mild bradycardia, or increased chest pain. Patients with STEMI demonstrated statistically significant quicker endoscopy (P = 0.01) and were more likely to undergo cardiac catheterization in advance of EGD (P < 0.01) than those with NSTEMI. No statistically significant differences were noted for peak troponin I (P = 0.21), APACHE II score at EGD (P = 0.55), or minor complications (P = 0.08) among patients with STEMI versus NSTEMI. Cardiac catheterization before EGD did not seem to affect results. Patients with APACHE II scores >16 experienced more minor complications (P = 0.02). CONCLUSIONS: EGD appears relatively safe for the diagnosis and management of upper gastrointestinal bleeding in patients with acute MI.

Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis.

BACKGROUND AND AIM: Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs. METHODS: Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. RESULTS: The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events. CONCLUSIONS: EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.

Prevalence of Osteoporosis in Cirrhosis: A Systematic Review and Meta-Analysis.

The prevalence of osteoporosis in individuals with cirrhosis varies based on the diagnostic approach and etiology of the underlying liver disease. This systematic review aims to evaluate the prevalence of osteoporosis in individuals with cirrhosis. Electronic databases were searched for studies reporting the prevalence of osteoporosis among patients with cirrhosis. The primary outcome was the presence of osteoporosis, as determined by a dual-energy x-ray absorptiometry (DEXA) scan. Secondary outcomes were levels of biochemical markers of bone metabolism, including calcium, vitamin D, phosphorus, and parathormone (PTH) levels. A cohort of 836 patients from 10 studies was included in the final analysis. The pooled rate of osteoporosis was 14.80% (95% CI: 14.19-15.49). Pooled levels of biochemical markers of bone metabolism were as follows: calcium 9.09 mg/dL (95% CI: 8.73-9.45), 25-hydroxyvitamin D (25-OH vitamin D) 15.41 ng/mL (95% CI: 14.79-16.03), phosphorus 15.41 mg/dL (95% CI: 2.99-3.51), and PTH 26.58 pg/mL (95% CI: 25.45-27.71). Pooled levels of liver biochemistries were: bilirubin 3.04 mg/dL (95% CI: 2.84-3.25), aspartate aminotransferase (AST) 65.35 U/L (95% CI: 61.39-69.31), alanine aminotransferase (ALT) 50.17 U/L (95% CI: 46.18-54.10), alkaline phosphatase 133.31 U/L (95% CI: 124.89-141.73), and albumin 3.25 g/dL (95% CI: 3.05-3.45). Cirrhosis appears to be associated with an increased risk for osteoporosis, with a pooled prevalence of 15%. This can include men and individuals younger than 50 years of age, a cohort not typically considered to be at an increased risk of osteoporosis. Levels of 25-hydroxyvitamin D and insulin-like growth factor-1 (IGF-1) were also significantly low. Further studies are required to evaluate the risk of osteoporosis based on the etiology and stage of cirrhosis, especially in younger males, to incorporate this into future prediction models for fragility fractures.

Efficacy of self-assembling peptide in mitigating delayed bleeding after advanced endoscopic resection of gastrointestinal lesions: A meta-analysis.

Background and study aims Advanced endoscopic resection techniques carry a risk of delayed bleeding (DB). A novel fully synthetic self-assembling peptide (SAP) has shown promising results in mitigating this risk. In this meta-analysis, we evaluated all available data and analyzed the effectiveness of SAP in reducing DB after advanced endoscopic resection of gastrointestinal luminal lesions. Patients and methods Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the use of SAP solution in patients undergoing advanced endoscopic resection of gastrointestinal lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results The initial search identified 277 studies, of which 63 relevant articles were reviewed. The final analysis included data from six studies comprising 307 patients that met inclusion criteria. The pooled rate of DB was 5.73 % (95 % confidence interval [CI] = 3.42-8.59). Mean patient age was 69.40 years ± 1.82. The weighted mean size of resected lesions was 36.20 mm (95 % CI = 33.37-39.02). Endoscopic submucosal dissection was used in 72.69 % (95 % CI = 67.62-77.48), while endoscopic mucosal resection was used in 26.42 % (95 % CI = 21.69-31.44) of the procedures. Among the 307 patients, 36 % were on antithrombotic medications. No adverse events (AEs) were attributable to using SAP, with a pooled rate of 0.00 % (95 % CI = 0.00-1.49). Conclusions SAP solution appears promising in reducing post-procedural DB after advanced endoscopic resection of high-risk gastrointestinal lesions with no reported AEs.

Efficacy of scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis.

Background: Endoscopic submucosal dissection (ESD) is an effective resection technique for early cancers and large gastrointestinal luminal lesions. However, ESD is technically challenging, with the potential for severe adverse events. Scissor-type ESD (ST-ESD) knives with an inner cutting edge and an electrically insulated external coating could mitigate some of these risks. This study aimed to evaluate the performance of ST electrosurgical knives when used for ESDs. Methods: Electronic databases were queried for studies from January 2005 through December 2022 evaluating the performance of ST-ESD knives. Fixed- and random-effects models were used to calculate pooled proportions. Heterogeneity was assessed using the I2 test and by constructing funnel plots, while bias was calculated using Egger and Harbord bias indicators. Results: Final analysis included data from 17 studies comprising 1652 ESD procedures. The pooled en bloc resection rate and R0 resection rate were 97.94% (95% confidence interval [CI] 97.20-98.57) and 94.32% (95%CI 93.11-95.43), respectively. The main adverse events were perforation and delayed post-procedural bleeding, with pooled rates of 1.07% (95%CI 0.63-1.62) and 1.86% (95%CI 1.26-2.56), respectively. There was no heterogeneity, as indicated by an I2 score of 0% (95%CI 0-44.50%). The mean procedure time was 67.45 min (95%CI 58.01-76.89). Conclusions: Our analysis shows that ST-ESD knives deliver consistently good performance across various locations in the gastrointestinal lumen and lesion sizes, with a good safety profile. This could be particularly appealing to newer adopters of ESD.

Efficacy and Safety of Peroral Endoscopic Myotomy (POEM) in Achalasia: An Updated Meta-analysis.

Background: Heller myotomy has been considered the standard surgical treatment for patients with achalasia. Since the initiation of peroral endoscopic myotomy (POEM), it has represented an alternative for treating patients with achalasia. Over the years, numerous prospective and retrospective studies with POEM use for achalasia have been published. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia. Methods: Publications investigating the safety and efficacy of POEM in patients with achalasia were searched in Medline, Ovid Journals, Medline non-indexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects models. Results: The initial search identified 328 reference articles; of these, 34 relevant articles were selected and reviewed. Data was extracted from 20 studies (n=1753) which met the inclusion criteria. In pooled analysis, the clinical success of POEM at 3 months was 94% (95% CI=93-95). The pooled clinical success of POEM at 12 months was 91% (95% CI=90-92). The pooled rate of gastroesophageal reflux disease (GERD) was 21% (95% CI=19-23), esophagitis was reported in 16% (95% CI=15-18), pneumomediastinum in 4% (95% CI=3-6), cervical emphysema in 12% (95% CI=10-13), pneumoperitoneum in 8% (95% CI=7-10), pneumothorax in 5% (95% CI=4 - 6), pleural effusion in 3% (95% CI=2-3), post-operative bleeding in 4.29% (95% CI=1.91 -7.61) and aspiration pneumonia in 3.08% (95% CI=1.13-5.97) of the patients after POEM. Conclusion: This meta-analysis suggests that POEM is a highly effective and safe endoscopic treatment for patients with achalasia and a reasonable alternative to Heller myotomy.

Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis.

BACKGROUND: Bariatric surgery leaks can result in significant morbidity and mortality. Endoscopic placement of self-expandable stents (SESs) is emerging as a less-invasive alternative to surgery for the treatment of leaks. OBJECTIVE: To evaluate the success of SESs in the treatment of bariatric surgery leaks. DESIGN: Studies using SESs in the management of bariatric surgery leaks were selected. Success of SES treatment was defined as radiographic evidence of leak closure after stent removal. Articles were searched in MEDLINE, PubMed, Ovid, and Cochrane Register of Controlled Trials. Pooled proportions were calculated by using fixed- and random-effects models. Publication bias was calculated by using the Begg-Mazumdar and Harbord bias estimators. RESULTS: A total of 189 relevant articles were reviewed of which 7 studies (67 patients with leaks) met inclusion criteria. The pooled proportion of successful leak closures by using SESs was 87.77% (95% CI, 79.39%-94.19%). The pooled proportion of successful endoscopic stent removal was 91.57% (95% CI, 84.22%-96.77%). Stent migration was noted in 16.94% (95% CI, 9.32%-26.27%). Test of heterogeneity gave a P value >.10. There was no publication bias. LIMITATIONS: Small retrospective studies, different types of stents used. CONCLUSION: Endoscopic placement of SESs is a minimally invasive, safe, and effective alternative in the management of leaks after bariatric surgery. The use of SESs can minimize the need for surgical revision and improve patient outcomes.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis.

BACKGROUND: Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges. AIM: To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events. METHODS: We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI). RESULTS: We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95). CONCLUSION: Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Adverse events in fecal microbiota transplantation: a systematic review and meta-analysis.

Background: Fecal microbiota transplantation (FMT) is a highly efficacious procedure used most commonly for the treatment of recurrent Clostridioides difficile infection (CDI). Despite the high value of incorporating FMT into practice, there remain concerns about its safety. To the best of our knowledge, there has not been an updated meta-analysis reporting pooled rates of adverse events in FMT for CDI. Methods: A search for studies of FMT in patients with CDI was performed with the rate of serious adverse events (SAEs) related to FMT evaluated as the primary outcome. Secondary outcomes included SAEs unrelated to FMT and minor adverse events associated with FMT. A pooled analysis was then performed. Results: Initial search identified 378 reference articles. Data were extracted from the 61 of these studies that met the inclusion criteria, comprising 5099 patients. Pooled analysis showed that SAEs related to FMT developed in less than 1% of patients. The pooled rate of SAEs not related to FMT was higher at 2.9%. The pooled rate of minor adverse events also showed infrequent self-limited gastrointestinal and systemic discomfort. Conclusions: This meta-analysis supports FMT as a safe option for treating recurrent CDI. Future randomized trials are needed to improve our current understanding of FMT safety and further examine the improvements in the quality of life of patients treated with FMT compared to standard therapy of antibiotics.