Diabetes mellitus and the risk of progression or malignancy of pancreatic cystic neoplasms in patients undergoing surveillance: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Patients with pancreatic cystic neoplasms (PCN) generally undergo surveillance by cross-sectional imaging or endoscopic-ultrasound due to their pre-malignant potential. Appearance of certain cyst characteristics during surveillance is associated with aggressive behavior or presence of malignancy. Patient characteristics associated with progression or induction of malignancy in PCN is unclear from current studies. We performed this meta-analysis to determine the patient characteristics associated with progression or malignancy in patients with PCN who undergo surveillance. METHODS: We performed a systematic research of several electronic databases for all the studies on surveillance of PCN which reported demographic data of patients who had progression or malignancy and controls. We calculated Risk ratio (RR) or Hazard ratio (HR) with 95% confidence interval (CI) for each variable. Mantel- Haenszel method or Inverse-variance model was used to pool data of progression or malignant transformation into fixed or random effect model meta-analysis. RESULTS: 11observational studies, 4 assessing risk factors for malignancy (3955 patients) and 7 evaluating risk factors for progression of PCN (3144 patients) were included in the meta-analysis. Diabetes mellitus was associated with higher risk for malignant transformation as well as progression of PCN (RR = 1.54, CI 1.23, 1.92). Advanced age was associated with higher risk of progression. Male gender had higher risk for malignant transformation but not progression of PCN. CONCLUSION: Diabetes is associated with an increased risk of both malignancy and progression of PCN in patients who undergo surveillance. Advanced age is also associated with higher risk of progression of PCN.

Comparison of clinical outcomes of multiple plastic stents and covered metal stent in refractory pancreatic ductal strictures in chronic pancreatitis- a systematic review and meta-analysis.

BACKGROUND: Symptomatic pancreatic duct (PD) strictures in chronic pancreatitis refractory to single plastic stenting are usually managed by placement of multiple plastic stents (MPS). Fully covered self-expanding metallic stents (FCSEMS) have also been used in the management of these patients. However, the overall efficacy and safety of different types of stents is unclear from the currently available studies. We performed this meta-analysis to assess the efficacy and complications from MPS and FCSEMS in patients with PD strictures refractory to treatment with single plastic stents. METHODS: Several electronic databases were searched for all the studies evaluating the outcome of placement of multiple plastic stents and fully covered metal stents in patients with PD strictures refractory to single plastic stenting. We calculated the Weighted Pooled Ratio (WPR) with Confidence Interval (CI) between the MPS and FCSEMS. RESULTS: A total of 13 studies (including 2 abstracts) were included in the analysis. MPS were placed in 106 patients and FCSEMS in 192 patients. Improvement in pain after stenting (P = 0.794), risk of recurrence of pain after removal of stent (P = 0.48) and stricture recurrence after stent removal (P = 0.52) were comparable between MPS and FCSEMS. Risk of endoscopic re-intervention was also comparable between metal stents and MPS. However, FCSEMS was associated with overall higher risk of adverse events (P < 0.0001). CONCLUSION: FCSEMS are comparable to multiple plastic stents in the treatment of symptomatic refractory PD strictures. However, use of FCSEMS is associated with increased risk of adverse events.

Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Unresectable malignant biliary strictures are generally managed by palliative stent placement for drainage of biliary tree. Recently, radiofrequency ablation (RFA) has been used to improve the patency of biliary stents in these patients. Several studies have evaluated the effectiveness of biliary stent placement with RFA on stent patency and patient survival with variable results. We performed this meta-analysis to evaluate the efficacy and safety of biliary stent placement with RFA compared with stent placement alone in patients with malignant biliary strictures. METHODS: We performed a comprehensive search of electronic databases for all studies comparing RFA with biliary stent placement versus stent placement only. Measured outcomes included patient survival, stent patency, and procedure-related adverse events. An inverse variance method was used to pool data on stent patency into a random-effects model. Cox-regression analysis was used to calculate hazard ratio for survival analysis. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework to interpret our findings. RESULTS: Nine studies (including 2 abstracts) with a total of 505 patients were included in the meta-analysis. The pooled weighted mean difference in stent patency was 50.6 days (95% confidence interval [CI], 32.83-68.48), favoring patients receiving RFA. Pooled survival analysis of the reconstructed Kaplan-Meier data showed improved survival in patients treated with RFA (hazard ratio, 1.395; 95% CI, 1.145-1.7; P < .001). However, RFA was associated with a higher risk of postprocedural abdominal pain (31% vs 20%, P = .003). Our analysis did not show significant difference between the RFA and stent placement-only groups with regard to the risk of cholangitis, acute cholecystitis, pancreatitis, and hemobilia. CONCLUSIONS: In the light of this limited data based on observational studies, RFA was found to be safe and was associated with improved stent patency in patients with malignant biliary strictures. In addition, RFA may be associated with improved survival in these patients.

Meta-analysis of the performance of ultrathin vs. standard colonoscopes.

Background and study aims Colonoscopy should reliably intubate the cecum with minimal patient discomfort and without complications. Use of thinner endoscopes to overcome pain during the procedure has shown promise. However, the use of thinner scopes could lead to excess looping and difficulty with therapeutic procedures. The aim of this meta-analysis was to analyze the performance of ultrathin colonoscopes (UTC) and standard colonoscopes for routine colonoscopy. Patients and methods We searched several electronic databases for all randomized controlled trials and nonrandomized (prospective) studies that compared the efficacies of UTC (diameter ≤ 9.8 mm) and standard colonoscopes. We used fixed effect or random effects models to compare cecal intubation rate, cecal intubation time, pain score, and polyp and adenoma detection rates using standard mean differences (SMD) or odds ratios (OR) with 95 % confidence intervals (CI). Results Seven studies (2191 patients) met the inclusion criteria. There was no significant heterogeneity among studies except for pain scores. The cecal intubation rate was higher with UTC (OR 2.30; 95 %CI 1.31 to 4.03). There was no difference in the cecal intubation time between UTC and standard colonoscopes. Pain scores were significantly lower with UTC than with standard colonoscopes (SMD - 0.59, 95 %CI - 0.93 to - 0.25). Polyp and adenoma detection rates were similar for both types of colonoscope. Conclusion Use of UTC appears to improve the cecal intubation rate and reduce abdominal pain but does not affect polyp detection. Future trials are needed to evaluate the therapeutic performance of UTC vs. standard colonoscopes.

Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis.

BACKGROUND AND AIM: Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta-analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak. METHODS: We carried out a systematic search in several electronic databases for randomized controlled trials (RCT) and observational studies (OS) comparing the risk of PEP after biliary stenting with or without ES. The Mantel-Haenszel method was used to pool data of adverse outcomes into fixed or random effect model meta-analyses. RESULTS: Seventeen studies (five RCT and 12 OS) with a total of 2710 patients met the inclusion criteria. No significant difference was observed in the risk of PEP with biliary stenting with and without ES (RD -0.01; 95% confidence interval [CI] -0.03, 0.01). In a subgroup analysis of stenting for biliary obstruction, no difference in the risk of PEP was observed with or without ES. However, ES was associated with lower risk of PEP in patients undergoing biliary stenting for bile leak (RD -0.05; CI -0.10, -0.01). CONCLUSIONS: ES shows risk reduction in prevention of PEP in patients undergoing endoscopic stenting for bile leak. However, placement of biliary stent without ES is not associated with an increased risk of PEP in patients with distal bile duct obstruction with involvement of pancreatic duct.

Efficacy and safety of, and patient satisfaction with, colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection.

OBJECTIVE: To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI). METHODS: A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into 'community-acquired' and 'hospital-acquired' CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT. RESULTS: Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported. CONCLUSION: FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.

Relationship of symptom duration and fecal bacteriotherapy in Clostridium difficile infection-pooled data analysis and a systematic review.

OBJECTIVE: Clostridium difficle-associated infection (CDI) is usually treated with antibiotics; nevertheless, the infection has a high relapse rate. Case series and case reports using fecal microbiota transplant (FMT) for CDI show promising results. However, there are no large studies to provide evidence for the efficacy of this therapy. The aim of this pooled patient data meta-analysis was to determine the efficacy of FMT in CDI. METHODS: We performed a literature search for FMT for CDI or pseudomembranous colitis. Individual patient data were obtained from each study. The primary endpoint was to assess the rate of diarrhea resolution. Secondary endpoints were to identify variables associated with treatment failure and side effects of therapy. RESULTS: A total of 289 patients from 25 published articles who received FMT for CDI were included in the pooled data analysis. FMT had an overall success rate of 91.2%. On univariate analysis, shorter duration of symptoms before FMT (< 60 days) and gastroduodenal route of fecal instillation were associated with treatment failure. On multivariate regression analysis, shorter duration of symptoms (< 60 days) before the FMT (OR= 11.08; p = 0.0009) was associated with treatment failure. Reported adverse events following FMT were irritable bowel syndrome (n = 1), symptoms of mild enteritis (n = 3), and suspected peritonitis following the procedure (n = 1). CONCLUSION: FMT is a safe and effective treatment option for CDI. Shorter duration of symptoms (< 60 days) before administering FMT is associated with treatment failure.

Body mass index predicts cecal insertion time: the higher, the better.

BACKGROUND: It is essential to determine the factors that predict prolonged procedural time during colonoscopy. The aim of this study was to determine the effect of body mass index (BMI) on cecal insertion time (CIT) during colonsocopy. METHODS: Consecutive outpatients who received colonoscopies over a 10 month period (April-October 2007) were enrolled. Exclusion criteria included colonic resection, strictures or exophytic masses precluding colonic evaluation. Data were collected for age, sex, race, height, weight, BMI, waist circumference, prior history of abdominal or pelvic surgery, history of diverticulosis, participation of fellow, CIT, quality of colon cleansing and the amount of sedation used during the procedure. RESULTS: A total of 1430 patients (586 men and 844 women; mean age 60.3 years) were included in the final analysis. The mean CIT was 648.5 seconds (SE = 11.47). Older age, female gender, fellow involvement, poor bowel preparation and lower BMI were associated with prolonged mean CIT on linear regression analysis ((R2) = 0.116; P < 0.001). Mean CIT declined linearly with increasing BMI. CONCLUSION: A higher BMI is strongly associated with progressively shorter CIT.