Management of post-bariatric complications. Our Center experience and literature review.

Bariatric surgery is recognized as the most effective treatment for morbid obesity, maintaining a stable weight reduction in the long term and reducing comorbidities, with a favorable impact on mortality. The aim of this study is to evaluate the complication rate and treatment techniques adopted in all patients undergoing bariatric surgery procedures in our center. From May 2017 to March 2020, 91 patients with morbid obesity are admitted to the Department of Medical and Surgical Science of the University Hospital of Foggia undergoing bariatric surgery. Seventyone patients underwent sleeve gastrectomy, nineteen gastric bypass and one mini-gastric bypass, five of these were redo operation procedures. Regarding postoperative complications (8,8%), there were 1 gastric leak (1,09%), 4 bleedings (4,39%) - 1 intraluminal bleeding and 3 intra-abdominal bleedings, 2 port-sites infections (2,19%) and 1 haemoperitoneum (1,09%). In our center we have also treated 3 cases of complications after bariatric surgery procedures performed in others centers. There were no deaths. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. Flexible endoscopy has become an essential tool in managing bariatric surgery patients and offers the benefit of providing both diagnostic and therapeutic applications. KEY WORDS: Bariatric surgery, Bleeding post-bariatric surgery, Complications bariatric surgery, Gastric bypass, Leak post-sleeve gastrectomy, Mini invasive approach, Sleeve gastrectomy.

Endocuff-assisted versus Cap-assisted Colonoscopy in Increasing Adenoma Detection Rate. A Meta-analysis.

BACKGROUND AND AIMS: Several add-on devices have been developed to increase rates of colon adenoma detection. We aimed to compare the endocuff-assisted colonoscopy with cap-assisted colonoscopy through a pairwise meta-analysis of randomized trials. METHODS: We searched the PubMed/Medline and Embase database through March 2020 and identified 6 randomized controlled trials (comprising 2,027 patients). The primary outcome was adenoma detection rate; secondary outcomes included sessile serrated adenoma detection rate, mean adenoma per colonoscopy, cecal intubation rate and time to reach cecum. Safety data were also analyzed. We performed pairwise meta-analysis through a random effects model and expressed data as risk ratio and 95% confidence interval. RESULTS: Overall, pooled adenoma detection rate was 48.1% (39.3-56.8%) with endocuff and 40.5% (30.4- 50.6%; risk ratio 1.14, 0.96-1.35) with cap. Proximal adenoma detection rate was 45.7% (36.8-54.7%) and 24% (17-45.1%) with endocuff and cap, respectively (risk ratio 2.04, 0.93-4.49), whereas endocuff outperformed cap-assisted colonoscopy in detecting diminutive (≤ 5 mm) adenomas (risk ratio 2.74, 1.53-4.90) and in terms of mean adenoma per colonoscopy (mean difference 0.31, 0.05 -0.57; p=0.02). Sessile serrated adenoma detection rate (risk ratio 1.36, 0.72-2.59), cecal intubation rate (risk ratio 0.99, 0.98-1.00), and time to reach cecum (6.87 min versus 6.87 min) were similar between the two groups. No serious adverse event was observed. CONCLUSION: Endocuff-assisted colonoscopy seems to provide a higher adenoma detection rate as compared to cap-assisted colonoscopy, in particular concerning smaller diminutive polyps.

Impact of fellow participation on colon adenoma detection rates: a multicenter randomized trial.

BACKGROUND AND AIMS: There are limited and conflicting data on the impact of fellow participation in improving the colon adenoma detection rate. We performed a multicenter randomized controlled trial to evaluate whether fellow involvement might have a beneficial effect on adenoma detection rate. METHODS: The trial was conducted at 4 tertiary hospitals between April and December 2019. Eight hundred twelve patients were randomized to undergo colonoscopy performed by a fellow under the supervision of a staff endoscopist or by an attending physician alone. RESULTS: No significant differences in demographic or adenoma risk factors were detected between the 2 groups. The adenoma detection rate in the intervention group was 44.8% versus 37.1% in the control arm (P = .02). The mean number of adenomas per colonoscopy was significantly higher in the intervention group (0.65 ± 0.3 vs 0.53 ± 0.2 in the control arm, P < .001). The polyp detection rate was 69.7% in the intervention group and 62.5% in the control arm (P = .03), whereas rates of advanced and sessile/serrated adenoma detection were not different between the trial arms (P = .50 and .42, respectively). In the subgroup of more experienced fellows, the adenoma detection rate and polyp detection rate were 49.5% and 75.7%, respectively. No difference was observed between less-experienced fellows and attending physicians alone (P = .53 and 0.86, respectively). The level of bowel preparation and fellow involvement were significant predictors of increased adenoma detection rate in a multivariate analysis. CONCLUSIONS: Our multicenter trial represents the first prospective validation of the beneficial role of fellow involvement in colonoscopy procedures. (Clinical trial registration number: NCT03908229.).

Needle-based confocal laser endomicroscopy in pancreatic cysts: a meta-analysis.

There is currently limited evidence supporting the use of needle-based confocal laser endomicroscopy in pancreatic cystic lesions. Aim of this study was to provide a pooled estimate of the diagnostic performance and safety profile of this technique in patients with pancreatic cysts. Computerized bibliographic search on the main databases was performed through November 2019. Pooled effects were calculated using a random-effects model by means of DerSimonian and Laird test. Primary endpoint was diagnostic accuracy. Secondary outcomes were pooled sensitivity, specificity, and mean procedural time. Ten studies enrolling 536 patients were included. Eight articles, of which five prospective series, compared confocal laser endomicroscopy to cytology/cystic fluid analysis. Most patients were female and body/tail was the most frequent location of pancreatic cysts. Mucinous cysts were prevalent in most of the included studies. Diagnostic accuracy with confocal laser endomicroscopy was 88.6% (83.7-93.4%) and sensitivity analysis according to study quality, design, and treatment arms confirmed the above reported result. Pooled sensitivity and specificity were 82.4% (74.7-90.1%) and 96.6% (94.3-99%), respectively. Both accuracy and sensitivity resulted higher in patients with mucinous cysts (91.4 and 94.9%, respectively). Confocal laser endomicroscopy clearly outperformed fine-needle aspiration in terms of diagnostic accuracy (odds ratio 3.94, 1.58-9.82; P = 0.003). A mean of 6.094 minutes (4.91-7.26) was needed to complete the procedure and no significant adverse event was registered. Our meta-analysis speaks in favor of the use of needle-based confocal laser endomicroscopy as a safe and effective tool in the diagnostic algorithm of pancreatic cysts.

Diagnostic yield of EUS-guided through-the-needle biopsy in pancreatic cysts: a meta-analysis.

BACKGROUND AND AIMS: There is currently limited evidence supporting the use of EUS-guided through-the-needle biopsy for sampling pancreatic cystic lesions. The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance of through-the-needle biopsy for sampling of pancreatic cysts. METHODS: A bibliographic search on the main databases was performed in September 2019. Pooled effects were calculated using a random-effects model by means of the DerSimonian and Laird test. The primary outcome was sample adequacy. Additional endpoints were diagnostic accuracy, optimal histologic core procurement, mean number of needle passes, pooled specificity, and sensitivity. Adverse event rates were also analyzed. RESULTS: Eleven studies enrolling 490 patients were included. Eight articles compared through-the-needle biopsy with cytology/cystic fluid analysis. Most patients were female, and the body/tail was the most frequent location of cystic lesions. Sample adequacy with through-the-needle biopsy was 85.3% (78.2%-92.5%), and subanalysis performed according to cyst morphology, size, and location confirmed the result. Through-the-needle biopsy clearly outperformed FNA both in terms of sample adequacy (odds ratio, 4.83; 95% confidence interval, 1.63-14.31; P =.004) and diagnostic accuracy (odds ratio, 3.44; 95% confidence interval, 1.32-8.96; P =.01). The pooled diagnostic accuracy rate, sensitivity, and specificity of through-the-needle biopsy were 78.8%, 82.2%, and 96.8%, respectively. A mean of 3.121 (2.98-3.25) passes through the cyst was needed to obtain adequate histologic samples. The incidence rates of mild bleeding and pancreatitis were 4% and 2%, respectively. CONCLUSION: Our meta-analysis speaks in favor of the use of through-the-needle biopsy as a safe and effective tool in EUS-guided tissue acquisition of pancreatic cysts.

Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: A meta-analysis.

BACKGROUND AND OBJECTIVE: Robust data in favor of clear superiority of 22G fine-needle biopsy (FNB) over 22G FNA for an echoendoscopic-guided sampling of pancreatic masses are lacking. The objective of this study is to compare the diagnostic outcomes and sample adequacy of these two needles. MATERIALS AND METHODS: Computerized bibliographic search on the main databases was performed and restricted to only randomized controlled trials. Summary estimates were expressed regarding risk ratio (RR) and 95% confidence interval. RESULTS: A total of 11 trials with 833 patients were analyzed. The two needles resulted comparable in terms of diagnostic accuracy (RR 1.02, 0.97-1.08; P = 0.46), sample adequacy (RR 1.01, 0.96-1.06; P = 0.61), and histological core procurement (RR 1.01, 0.89-1.15; P = 0.86). Pooled sensitivity in the diagnosis of pancreatic cancer was 93.1% (87.9%-98.4%) and 90.4% (86.3%-94.5%) with biopsy and aspirate, respectively, whereas specificity for detecting pancreatic cancer was 100% with both needles. Analysis of the number of needle passes showed a nonsignificantly positive trend in favor of FNB (mean difference: -0.32, -0.66-0.02; P = 0.07). CONCLUSION: Our meta-analysis stands for a nonsuperiority of 22G FNB over 22G FNA; hence, no definitive recommendations on the use of a particular device can be made.

Cirrhosis Is a Predictor of Adverse Events in Endoscopic Ultrasound Fine-Needle Aspiration: A Propensity-Score Analysis.

BACKGROUND: Cirrhotic patients are at increased risk of adverse events (AEs) after invasive procedures. However, the safety profile of endoscopic ultrasound (EUS) fine-needle aspiration in cirrhotic patients is still unknown. OBJECTIVES: To examine the AEs rate after EUS fine-needle aspiration in cirrhotic patients as compared to a control group of noncirrhotic patients. METHODS: Out of 735 patients with suspected abdominal lesions referred to our center between 2006 and 2018, after propensity-score matching, 2 groups were compared: 95 cirrhotics and 95 controls. Primary variables included rate of overall and serious AEs. Secondary endpoint was incidence of acute-on-chronic liver failure. RESULTS: Median age was 64 years, and pancreatic lesions represented the sampled tissue in 57 patients (60%) in each group (p = 1.0) with mean size of 22 mm in both cohorts (p = 0.3). Overall, 20 AEs (21%) of which 9 serious (9.4%) were observed in cirrhotic patients and 3 (3.1%) mild events were experienced by noncirrhotic subjects. Only liver cirrhosis was confirmed as a significant predictor of AEs in multivariate analysis (OR 8.11, 2.34-28; p = 0.001). Overall rate of infections was 6/95 (6.3%), of which 4 were serious (4.2%) in cirrhotics and 1/95 (1%) in the control group (p = 0.05). All serious infections led to the occurrence of acute-on-chronic liver failure. Minor bleeding events were more frequent in cirrhotic patients (4.2 vs. 0%; p = 0.04). CONCLUSIONS: The rate of AEs after EUS fine-needle aspiration is higher in cirrhotic patients, and acute-on-chronic liver failure may represent a serious complication of this procedure.

Statins decrease the risk of acute pancreatitis after endoscopic ultrasound fine-needle aspiration of pancreatic cysts.

BACKGROUND: Basic and clinical studies suggest that statins may prevent and even ameliorate acute pancreatitis. The present study was to evaluate whether statin decreases the risk of acute pancreatitis in patients undergoing endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts. METHODS: Out of 456 patients with pancreatic cysts referred to our center between 2006 and 2018, 365 were finally included in analyses: 86 were treated with statins and 279 were not at the time of endoscopic ultrasound fine-needle aspiration. We compared the acute pancreatitis incidence between the two groups, and we also compared other complications such as bleeding and infections. RESULTS: Median age was 64 years [interquartile range (IQR) 62-69] and median cyst size was 24 mm (IQR, 21-29). The most frequent histology was intraductal papillary mucinous neoplasm (45.3% and 42.3% in the two groups, respectively; P = 0.98). All 13 patients experiencing post-endoscopic ultrasound acute pancreatitis were from the control group (4.7%), of which 3 were classified as severe pancreatitis. None of statin users developed post-procedural acute pancreatitis (odds ratio: 0.15; 95% confidence interval: 0.03-0.98; P = 0.03). No difference was registered with regard to severe pancreatitis and other complications. CONCLUSIONS: Statins exert a beneficial role in preventing acute pancreatitis in patients with pancreatic cysts undergoing endoscopic ultrasound-guided fine-needle aspiration. If confirmed in prospective trials, our findings may pave the way to an extensive use of statins as prophylactic agents in pancreatic interventional endoscopy.

Diagnostic yield of Franseen and Fork-Tip biopsy needles for endoscopic ultrasound-guided tissue acquisition: a meta-analysis.

Background and study aims Although newer needle designs are thought to improve diagnostic outcomes of endoscopic ultrasound-guided fine-needle biopsy, there is limited evidence on their diagnostic performance. The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance and safety profile of Franseen and Fork-tip fine-needle biopsy needles. Patients and methods Computerized bibliographic search on the main databases was performed through March 2019. The primary endpoint was sample adequacy. Secondary outcomes were diagnostic accuracy, optimal histological core procurement, mean number of needle passes, pooled specificity and sensitivity. Safety data were also analyzed. Results Twenty-four studies with 6641 patients were included and pancreas was the prevalent location of sampled lesions. Overall sample adequacy with the two newer needles was 94.8 % (93.1 % - 96.4 %), with superiority of Franseen needle over Fork-tip (96.1 % versus 92.4 %, P  < 0.001). Sample adequacy in targeting pancreatic masses was 95.6% and both needles produced results superior to fine-needle aspiration (FNA) (odds ratio 4.29, 1.49 - 12.35 and 1.79, 1.01 - 3.19 with Franseen and Fork-tip needle, respectively). The rate of histological core procurement was 92.5%, whereas diagnostic accuracy and sensitivity were 95 % and 92.8 %, again with no difference between the two needles. Number of needle passes was significantly lower in comparison to FNA (mean difference: -0.42 with Franseen and -1.60 with Fork-tip needle). No significant adverse events were registered. Conclusion Our meta-analysis speaks in favor of use of newer biopsy needles as a safe and effective tool in endoscopic ultrasound-guided tissue acquisition.

Efficacy of hemostatic powders in upper gastrointestinal bleeding: A systematic review and meta-analysis.

BACKGROUND: There is limited evidence on the efficacy of hemostatic powders in the management of upper gastrointestinal bleeding. AIMS: Provide a pooled estimate of the efficacy and safety profile of hemostatic powders in digestive endoscopy. METHODS: A computerized bibliographic search on the main databases was performed through December 2018. Pooled effects were calculated using a random-effects model. The primary outcome was immediate hemostasis rate. Secondary outcomes were rebleeding rate (either at 7 and 30 days), bleeding-related mortality, and all-cause mortality rate. RESULTS: A total of 24 studies, of which three were randomized-controlled trials, with 1063 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95.3% (93.3%-97.3%) of patients, with no difference based on treatment strategy, hemostatic agent used, bleeding etiology. Success rate was slightly lower in spurting bleeding (91.9%). Hemostatic powders showed similar efficacy as compared to conventional endoscopic therapy (odds ratio: 0.84, 0.06-11.47; p = 0.9). Thirty-day rebleeding rate was 16.9% (9.8%-24%) with no difference in comparison to other endoscopic treatments (odds ratio 1.59, 0.35-7.21; p = 0.55). All-cause and bleeding-related mortality rates were 7.6% (4%-10.8%) and 1.4% (0.5%-2.4%), respectively. CONCLUSION: Novel hemostatic powders represent a user-friendly and effective tool in the management of upper gastrointestinal bleeding.

Response to repeat echoendoscopic celiac plexus neurolysis in pancreatic cancer patients: A machine learning approach.

BACKGROUND: /Objectives: Efficacy of repeat echoendoscopic celiac plexus neurolysis is still unclear. Aim of the study was to assess the efficacy of repeat celiac plexus neurolysis and to build an artificial neural network model able to predict pain response. METHODS: Data regarding 156 patients treated with repeat celiac plexus neurolysis between 2004 and 2019 were reviewed. Artificial neural network and logistic regression models were built to predict pain response after treatment. Performance of the models was expressed in terms of accuracy, positive predictive value, and positive likelihood ratio. RESULTS: Median age was 62 years (range 39-86) and most patients were male (66%) with pre-procedural visual analogue score 7. Fifty-one patients (32.6%) experienced treatment response, of which 6 (3.8%) complete pain suppression. Median duration of pain relief was 6 (2-8) weeks. Tumoral stage, interval from initial to repeat treatment, response to initial neurolysis, and tumor progression between the two treatments resulted as significant predictors of pain response. The performance of the artificial neural network in predicting treatment response was higher than regression model (area under the curve: 0.94, 0.89-0.97 versus 0.85, 0.78-0.89; p < 0.001). Positive predictive value and positive likelihood ratio resulted 90.3% and 19.35, respectively. Classification error rate was 5.7% with the artificial neural network compared to 14.7% of regression model (p < 0.001). These findings were confirmed through ten-fold cross validation. CONCLUSIONS: Pain response following repeat neurolysis is generally less pronounced than after initial treatment. Artificial neural network may help to identify those subjects likely to benefit from repeat neurolysis.

Antibiotics Do Not Decrease the Rate of Infection After Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts.

BACKGROUND: In spite of the weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions is routinely used in the clinical practice. AIMS: To compare a group of patients treated with antibiotics before fine-needle aspiration of pancreatic cystic lesions and a group who did not undergo antimicrobial prophylaxis. METHODS: Out of 335 patients with suspected pancreatic cystic lesions referred to our center between 2006 and 2018, after propensity score matching two groups were compared: 135 subjects who underwent endoscopic ultrasound fine-needle aspiration under antibiotic prophylaxis and 135 treated with no antimicrobial agents. Primary outcome was infection rate; secondary endpoints included other complications or antibiotic-related adverse events. RESULTS: Median age was 64 (interquartile range 61-68) and median cyst size was 24 mm (22-28), with no difference between groups. Overall, 10 adverse events (7.1%) of which 2 serious (1.4%) were observed in the antibiotic group and 8 (5.8%) of which 1 (0.7%) serious in the non-antibiotic group. Cyst infection was observed in 2 patients (1.4%) in the antibiotic group and 3 patients (2.2%) in the other cohort (p = 0.65). CONCLUSIONS: Prophylactic antibiotics do not seem to substantially reduce this risk of infection, and their routine use should be abandoned.

Comparative efficacy of long-term antibiotic treatments in the primary prophylaxis of spontaneous bacterial peritonitis.

BACKGROUND & AIMS: Several antibiotic treatments aiming to prevent spontaneous bacterial peritonitis (SBP) in cirrhotic patients with low-protein content in ascitic fluid have been tested; however, there are limited data on the comparative efficacy of these regimens. We assessed their comparative efficacy through a network meta-analysis and using GRADE criteria to appraise quality of evidence. METHODS: Through literature review through October 2018, we identified 10 randomized controlled trials comparing antibiotic treatments (norfloxacin, ciprofloxacin, trimethoprim/sulfamethoxazole and rifaximin) with each other or placebo. Primary outcome was SBP occurrence, with mortality rate and rate of other infections as secondary outcomes. RESULTS: In comparison with placebo, moderate quality evidence supports the use of norfloxacin and ciprofloxacin in primary prophylaxis of SBP (risk ratio 0.23; 95% CI, 0.09-0.56; P = 0.001 and 0.23; 0.07-0.79; P = 0.02 respectively) while only low quality evidence suggests superiority of rifaximin (risk ratio 0.15; 0.05-0.42). When antimicrobial agents were compared to each other, no significant difference was found. With regard to mortality, moderate quality supports the superiority of norfloxacin over placebo (risk ratio, 0.68; 95% CI, 0.47-0.99; P = 0.04), while ciprofloxacin and rifaximin showed only a non-significant benefit and no significant difference was found in the other comparisons. None of the tested antibiotics proved to significantly decrease the rate of other infections. CONCLUSIONS: Norfloxacin appears to have significant benefit both in terms of SBP prevention and mortality; ciprofloxacin represents a valuable option although without a clear survival benefit. Rifaximin shows interesting results but needs to be tested in further trials.

Full-spectrum versus standard colonoscopy for improving polyp detection rate: A systematic review and meta-analysis.

BACKGROUND AND AIM: Full-spectrum endoscopy represents a new endoscopic platform allowing a panoramic 330 degree view of the colon, but evidence of its superiority over standard colonoscopy is still lacking. Our study is the first meta-analysis comparing the efficacy of full-spectrum endoscopy with standard colonoscopy. METHODS: Through a systematic literature review until May 2017, we identified eight randomized-controlled trials. Primary outcomes were polyp detection rate and adenoma detection rate, while cecal intubation time and total colonoscopy time were secondary outcomes. Direct meta-analysis was performed using a random effects model. RESULTS: No difference in terms of polyp detection rate and adenoma detection rate was found (risk ratio: 1.00, 95% confidence interval 0.89-1.12, P = 0.96, and 1.05, 0.94-1.17, P = 0.40, respectively). Adenoma miss rate resulted significantly in favor of full-spectrum endoscopy (risk ratio: 0.35, 0.25-0.48, P < 0.01), although the difference was not significant for greater (>5 mm) and pedunculated lesions (risk ratio: 0.38, 0.09-1.60, P = 0.19, and risk ratio: 0.15, 0.01-3.00, P = 0.21, respectively). Cecal intubation time was not different between the two techniques (mean standardized difference: 0.22 min, -1.18 to 1.62, P = 0.76), while total colonoscopy time was significantly shorter when adopting full-spectrum endoscopy (mean difference: -2.60, -4.60 to -0.61, P = 0.01). Sensitivity analysis confirmed all the findings. CONCLUSIONS: Full-spectrum endoscopy appears as a promising and reliable technology able to significantly decrease the number of adenomas missed and procedural times, while its superiority over standard colonoscopy in terms of adenoma detection rate results is still unclear.