Effects of Glucagon-like Peptide-1 Receptor Agonists on Upper Endoscopy in Diabetic and Non-Diabetic Patients.

BACKGROUND AND AIMS: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) promote weight loss by suppressing appetite, enhancing satiety, regulating glucose metabolism and delaying gastric motility. We sought to determine whether GLP-1 RA use could impact sedated medical procedures like esophagogastroduodenoscopy (EGD). METHODS: We conducted a retrospective study on 35,183 patients who underwent EGD between 2019 and 2023, 922 of which were using a GLP-1-RA. Data were collected regarding demographics, diabetes status, retained gastric contents during EGD (RGC), incidence of aborted EGD, and necessity for repeat EGD. RESULTS: GLP-1 RA use was associated with a fourfold increase in the retention of gastric contents (p<0.0001), fourfold higher rates of aborted EGD (p<0.0001), and twice the likelihood of requiring repeat EGD (p=0.0001), even after stratifying for presence of diabetes. CONCLUSIONS: GLP-1 RA use can lead to delayed gastric emptying, affecting EGD adequacy regardless of the presence of diabetes, and may warrant dose adjustment to improve safety and efficacy of these procedures.

Immediate-use strategy is as safe and effective as delayed-use strategy following percutaneous endoscopic gastrostomy tube placement: A retrospective cohort study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is the most common enteral access for long-term feeding. The aim of our study is to assess the feasibility and safety of immediate PEG tube use after initial placement. METHODS: We conducted a single-center retrospective cohort study between August 2006 and August 2016. Prior to August 2011, tube feedings were delayed for ≥4 h after initial PEG placement, compared with immediate use (<1 h) after August 2011. Primary outcomes were complication rates within 30 days of placement. Secondary outcomes were impact of morbidity, mortality, length of stay, and need for repeat PEG placement. RESULTS: Our study included 1296 patients during the 10-year period, of which 704 underwent delayed use and 592 underwent immediate use (744 inpatient and 552 outpatient). There were no significant differences between the delayed-use and immediate-use PEG with regard to complications (3.4% vs 4.4%; P = 0.76). Subgroup analysis also reflected no significant differences in complications between inpatient and outpatient groups. For inpatients, there were no substantial differences in inpatient mortality (3.9% vs 3.3%; P = 0.70), mortality within 30 days of discharge (13.8% vs 13.1%; P = 0.15), readmissions (38.2% vs 34.3%; P = 0.23), repeat PEG placement (0.7% vs 1.5%; P = 0.46), and length of stay (13.3 vs 13.9 days; P = 0.99). CONCLUSION: Patients who received immediate enteral nutrition after PEG tube placement did not have any increased complications, morbidity, or mortality; and it is just as safe when compared with patients who received delayed feeding.

Periesophageal Tuberculosis Abscess Post-Liver Transplantation Successfully Treated With Lumen-Apposing Metal Stent Cyst Esophagostomy.

The therapeutic utility of ultrasound-guided endoscopy has grown significantly in recent years. In this report, we describe a case of extrapulmonary tuberculosis in a liver transplant recipient found to have an encapsulated fluid collection in the inferior mediastinum, which was drained with an endoscopic ultrasound-guided technique, precluding the need for percutaneous or surgical intervention.

Changing Trends in Liver Biopsy Practices: A Single-Center Analysis.

Introduction To assess the trends for liver biopsy (LB) indications, technique, and histopathologic diagnosis, we retrospectively evaluated liver biopsies in two one-year periods, separated by a decade. Methods A pathology database query was performed for all parenchymal LB in patients over 18 years (11/2017 to 10/2018) and compared to those performed over a one-year period, a decade ago. We identified 427 parenchymal liver biopsies in the recent group and 166 in the decade-old group. Results Elevated liver enzymes are the most common indication for LB. Non-alcoholic fatty liver disease (NAFLD) has become the most common diagnosis compared to 10 years ago, when it was viral hepatitis. Routes of LB were significantly different between the two groups, endoscopic ultrasound-guided liver biopsy (EUS-LB) (80.3% vs 0; p<0.0001), computed tomography-guided (0 vs 42.8%, p<0.0001), percutaneous by gastroenterologists (0% vs 29.5%, p<0.0001), and transjugular-LB (15.1% vs 17.6%, p<0.0001). The adequacy of the tissue for pathological diagnosis was similar, and there was no difference in adverse events. Conclusion At our institution, practice patterns have changed significantly for liver biopsy. There has been an increase in liver biopsy volume, and EUS guidance has become the most common approach for liver biopsy.

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.

Efficacy of cap-assisted endoscopy for the visualization of the major duodenal papilla: a systematic review and meta-analysis.

BACKGROUND AND AIMS: The current standard of practice is to use a duodenoscope for the evaluation of the major duodenal papilla (MDP). Recently, cap-assisted endoscopy (CAE), which uses a transparent cap at the tip of a standard front-viewing endoscope, has emerged as an alternative. METHODS: A systematic literature search was performed in several databases from inception to January 2023 to identify studies evaluating the efficacy of CAE for the evaluation of the MDP. RESULTS: Nine studies including 806 patients met our inclusion criteria. The pooled rate of technical success for CAE was 93.2% (95% confidence interval, 85.6-96.9; I2 = 84.6%). A subgroup analysis comparing CAE with a standard endoscope showed higher odds for the evaluation of the MDP with CAE (but not a duodenoscope, which was better than CAE) with an odds ratio of 57.294 (95% confidence interval, 17.767-184.755; I2 = 45.303%). CONCLUSIONS: CAE offers a significant advantage with high rates of complete MDP evaluation compared with standard forward-viewing endoscopy. However, CAE is associated with lower rates of success when compared with side-viewing endoscopes.

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

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

Gastrointestinal Bleeding Secondary to Splenic Artery Pseudoaneurysm: A Delayed Complication of a Lumen-Apposing Metal Stent.

Lumen-apposing metal stents (LAMSs) have been widely used for drainage of peripancreatic collections. A 71-year-old woman with a history of necrotizing pancreatitis who underwent LAMS placement 3 months ago for symptomatic pancreatic fluid collection presented with hematochezia and hemodynamic instability. Computed tomographic angiography of the abdomen showed concerns for stent erosion into the splenic artery. Esophagogastroduodenoscopy revealed a large pulsating nonbleeding vessel within the LAMS. She underwent a mesenteric angiogram, which showed splenic artery pseudoaneurysm, and coil embolization was performed. Gastrointestinal bleeding secondary to pseudoaneurysm should be considered in patients with recent LAMS placement who present with signs of gastrointestinal bleeding.

Safety of endoscopic mucosal resection of large colonic polyps in elderly patients: a systematic review and meta-analysis.

Background: Endoscopic mucosal resection (EMR) is a procedure commonly used for large sessile and flat polyps. However, it may cause bleeding, perforation, and complications related to anesthesia. There are limited data on the safety and efficacy of EMR in the elderly. Therefore, we conducted a comprehensive review and meta-analysis to assess EMR safety in elderly patients. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection for studies evaluating EMR for large colorectal lesions (>20 mm) in older patients (75+ years). Our primary result was post-polypectomy bleeding and perforation, while our secondary outcome was recurrence or residual polyp. Results: The meta-analysis included 6 studies with 2903 patients. The rate of post-polypectomy bleeding was 5.3% (95% confidence interval [CI] 2.3-11.7%), I 2=73.7%; and perforation was 1.9% (95%CI 0.9-3.8%), I 2=0%, in patients over 75 years old. The pooled risk of post-polypectomy bleeding was 2.4%, 95%CI 1.2-4.8%, I 2=0%; and perforation was 2.1%, 95%CI 0.7-5.8%, I 2=8.6%, in patients over 80 years old. The risk of post-polypectomy bleeding (odds ratio [OR] 0.922, 95%CI 0.359-2.367, I 2=0%); and perforation (OR 1.066, 95%CI 0.188-6.031, I 2=0%) did not differ significantly between patients aged over 80 and younger patients. The pooled rate of residual or recurrence of polyps in patients aged over 80 was significantly higher (25%, 95%CI 17-35.3%, I 2=59.5%) vs. younger patients (OR 2.234, 95%CI 1.549-3.223, I 2=0%). Conclusion: EMR is as safe for the elderly as it is for younger patients, and is not associated with a greater risk of bleeding or perforation.

Outcomes of Acute Gastrointestinal Bleeding in Patients With COVID-19: A Case-Control Study.

Background: Coronavirus disease 2019 (COVID-19) patients are at higher risk of acute gastrointestinal bleeding (AGIB) due to higher use of steroids, mechanical ventilation, and use of anticoagulation. We performed this study to compare outcomes of AGIB in COVID-19-positive patients and those without COVID-19 and AGIB. Methods: This was a case-control study including patients admitted from March 2020 to February 2021 with the diagnosis of AGIB. Patients were divided into two groups: COVID-19-positive and non-COVID-19 patients. Our primary outcomes were in-hospital or 30 days mortality and length of stay. Secondary outcomes were the rate of rebleeding, the need for intensive care unit (ICU) level of care, and the need for blood transfusion. Results: Eighteen COVID-19-positive patients and 54 matched non-COVID-19 patients were included. The COVID-19-positive patients less frequently had endoscopies performed (33.3% vs. 74.1%, P = 0.0059) and had greater steroid use (83.3% vs. 14.8%, P < 0.0001) compared to non-COVID-19 patients. ICU stays were more likely in the COVID-positive patients (odds ratio (OR): 20.41; 95% confidence interval (CI): 2.59 - 160.69; P = 0.004) as was longer hospital length of stay (OR: 1.08; 95% CI: 1.03 - 1.13; P = 0.002). Mortality, readmission within 30 days, need for blood transfusion, and having rebleeding during the admission did not differ for COVID-19 and non-COVID-19 patients. Conclusion: COVID-19 patients with AGIB are more likely to require ICU admission and had a longer length of stay. Despite the significantly lower rate of endoscopic procedures performed in patients with COVID-19, need for blood transfusion, mortality and rebleeding were not significantly different.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Nonagenarians: A Systematic Review and Meta-Analysis.

BACKGROUND: Recent advances in modern medicine have translated into increase in life expectancy in the USA and with that, a rise in the demand for invasive procedures in elderly patients. Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for managing various benign and malignant pancreatobiliary conditions and can be associated with various adverse events. AIM: We performed a systematic review and meta-analysis to evaluate outcomes of ERCP in nonagenarians. METHODS: A comprehensive literature search was performed in Embase, MEDLINE, Web of Science, and Cochrane Review library until July 2020. Our primary outcomes were the rate of technical success and adverse events in nonagenarians. Secondary outcomes were comparison of technical success and adverse events compared with younger patients. RESULTS: The initial search revealed 4933 studies, of which 24 studies with 5521 patients met our inclusion criteria. Pooled technical success rate of ERCP in nonagenarians was 92%, and pooled adverse event rate was 7.8%. There was no significant difference in technical success rate and overall rate of adverse events comparing ERCP outcomes in nonagenarians with a relatively younger population. The risk of post-ERCP bleeding was significantly higher in nonagenarians compared to younger patients with OR = 1.986 [1.113-3.544], I2 = 0. ERCP-related mortality was also significantly higher in nonagenarians compared to younger patients with OR = 4.720 [1.368-16.289], I2 = 0. CONCLUSION: There was no significant difference in technical success rate and risk of adverse events related to ERCP in nonagenarians compared to younger patients. However, the risk of bleeding and procedure-related mortality was significantly higher.

Acute Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis.

BACKGROUND/AIMS: More than 100 million people to date have been affected by the coronavirus disease-2019 (COVID-19) pandemic. Patients with COVID-19 have a higher risk of bleeding complications. We performed a systematic review and meta-analysis to evaluate the outcomes of COVID-19 patients with signs and symptoms of acute gastrointestinal bleeding (GIB). METHODS: A systematic literature search was carried out for articles published until until November 11, 2020, in the Embase, MEDLINE, Web of Science, and Cochrane Library databases. We included studies on COVID-19 patients with signs and symptoms of GIB. RESULTS: Our search yielded 49 studies, of which eight with a collective 127 patients (86 males and 41 females) met our inclusion criteria. Conservative management alone was performed in 59% of the patients, endoscopic evaluation in 31.5%, and interventional radiology (IR) embolization in 11%. Peptic ulcer disease was the most common endoscopic finding, diagnosed in 47.5% of the patients. Pooled overall mortality was 19.1% (95% confidence interval [CI]; 12.7%-27.6%) and pooled mortality secondary to GIB was 3.5% (95% CI; 1.3%-9.1%). The pooled risk of rebleeding was 11.3% (95% CI; 6.8%-18.4%). CONCLUSION: The majority of COVID-19 patients with GIB responded to conservative management, with a low mortality rate associated with GIB and the risk of rebleeding. Thus, we suggest limiting endoscopic and IR interventions to those with hemodynamic instability and those for whom conservative management was unsuccessful.

Single-pass 1-needle actuation versus single-pass 3-needle actuation technique for EUS-guided liver biopsy sampling: a randomized prospective trial (with video).

BACKGROUND AND AIMS: Several reports have validated EUS-guided liver biopsy sampling (EUS-LB) as safe and effective. Nineteen-gauge EUS aspiration (FNA) or core (fine-needle biopsy [FNB]) needles are used, but different needle techniques can yield variable outcomes. Some data show that 1 pass (single liver puncture) with 1 actuation (1 to-and-fro needle movement) may be enough to obtain a satisfactory specimen. However, there has not been a head-to-head comparison of single versus multiple needle actuations for EUS-LB. METHODS: This was a prospective randomized trial of EUS-LB in 40 patients comparing tissue yields and adequacy using 1 pass, 1 actuation (1:1) versus 1 pass 3 actuations (1:3) of an FNB needle. The primary outcome was number of complete portal triads (CPTs). Secondary outcomes were length of the longest piece, aggregate specimen length, number of cores >9 mm, and adverse events (AEs). Computerized randomization determined selection (either 1:1 or 1:3 with fanning technique). Sample lengths were measured before pathologic processing. RESULTS: Both groups had similar demographics and indications for EUS-LB. All biopsy samples were adequate for pathologic interpretation. Compared with 1:1, biopsy sampling with 1:3 yielded more CPTs (mean [standard deviation], 17.25 [6.2] vs 24.5 [9.88]; P < .008) and longer aggregate specimen length (6.89 cm [1.86] vs 12.85 cm [4.02]; P < .001). AEs were not statistically different between the techniques. No severe AEs were noted. CONCLUSIONS: EUS-LB using the 1:3 technique produced longer liver cores with more CPTs than the 1:1 technique with an equivalent safety profile. Two needle passes are more likely to provide tissue adequacy according to the American Association for the Study of Liver Diseases guidelines. (Clinical trial registration number: UMIN 000040101.).

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study.

BACKGROUND: Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered. METHODS: This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula. RESULTS: 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases. CONCLUSIONS: The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.