A Systematic Review and Meta-Analysis: A Prior Appendectomy Does Not Increase the Risk of Severe Clostridioides difficile Infection or Recurrence.

BACKGROUND AND OBJECTIVES: There is conflicting evidence regarding the association between a prior appendectomy and severity of Clostridioides difficile infection. The aim of this study was to perform a systematic review and meta-analysis to evaluate this association. PATIENTS AND METHODS: Comprehensive review of multiple databases was performed up to May 2022. The primary outcome assessed was the rate of severe Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix. The secondary outcomes assessed were recurrence, mortality, and colectomy rates associated with Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix. RESULTS: Eight studies with 666 patients with a prior appendectomy and 3580 patients without an appendectomy were included. The odds ratio of severe Clostridioides difficile infection in patients who underwent prior appendectomy was 1.03 (95% CI 0.6-1.78, p = 0.92). The odds ratio of recurrence in patients who underwent prior appendectomy was 1.29 (95% CI 0.82-2.02, p = 0.28). The odds ratio of colectomy due to Clostridioides difficile infection in patients who underwent prior appendectomy was 2.16 (95% CI 1.27-3.67, p = 0.004). The odds ratio of mortality due to Clostridioides difficile infection in patients with a prior appendectomy was 0.92 (95% CI 0.62-1.37, p = 0.68). CONCLUSION: Patients with appendectomy are not at increased risk for developing severe Clostridioides difficile infection or recurrence. Further prospective studies are needed to establish these associations.

New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

BACKGROUND: Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB. METHODS: We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI). RESULTS: The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I2 = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I2 = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP. CONCLUSION: SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.

A Comparative Study of Acute Alcoholic Hepatitis vs. Non-Alcoholic Hepatitis Patients from a Cohort with Chronic Alcohol Dependence.

The rate of alcoholic hepatitis (AH) has risen in recent years. AH can cause as much as 40-50% mortality in severe cases. Successful abstinence has been the only therapy associated with long-term survival in patients with AH. Thus, it is crucial to be able to identify at-risk individuals in order to implement preventative measures. From the patient database, adult patients (age 18 and above) with AH were identified using the ICD-10 classification from November 2017 to October 2019. Liver biopsies are not routinely performed at our institution. Therefore, patients were diagnosed with AH based on clinical parameters and were divided into "probable" and "possible" AH. Logistic regression analysis was performed to determine risk factors associated with AH. A sub-analysis was performed to determine variables associated with mortality in AH patients. Among the 192 patients with alcohol dependence, there were 100 patients with AH and 92 patients without AH. The mean age was 49.3 years in the AH cohort, compared to 54.5 years in the non-AH cohort. Binge drinking (OR 2.698; 95% CI 1.079, 6.745; p = 0.03), heavy drinking (OR 3.169; 95% CI 1.348, 7.452; p = 0.01), and the presence of cirrhosis (OR 3.392; 95% CI 1.306, 8.811; p = 0.01) were identified as characteristics more commonly found in the AH cohort. Further, a higher inpatient mortality was seen in those with a probable AH diagnosis (OR 6.79; 95% CI 1.38, 44.9; p = 0.03) and hypertension (OR 6.51; 95% CI 9.49, 35.7; p = 0.02). A higher incidence of mortality was also noted among the non-Caucasian race (OR 2.72; 95% CI 4.92; 22.3; p = 0.29). A higher mortality rate despite a lower incidence of alcohol use among non-Caucasian patients may indicate healthcare disparities.

Single-incision needle-knife biopsy for the diagnosis of GI subepithelial tumors: a systematic review and meta-analysis.

BACKGROUND AND AIMS: A histologic diagnosis of GI subepithelial tumors (SETs) is important because of the malignant potential of these lesions. The current modalities of choice, including EUS-guided FNA and biopsy (EUS-FNA/FNB) have demonstrated suboptimal diagnostic success. Single-incision with needle-knife (SINK) biopsy has emerged as an alternative diagnostic approach to increase tissue acquisition and diagnostic success. The aim of this study was to perform a systematic review and meta-analysis to evaluate the technical success, diagnostic success, and adverse events of SINK biopsy. METHODS: We searched multiple databases including PubMed, EMBASE, CINAHL, Cochrane, Web of Science, and Google Scholar from inception to July 2022. The primary outcomes assessed were the technical success and diagnostic success of SINK in GI SETs. The secondary outcomes assessed were adverse events and whether immunohistochemical analysis could be successfully performed on tissue samples obtained via SINK. RESULTS: Seven studies with a total of 219 SINK biopsy procedures were included in this meta-analysis. The technical success rate was 98.1% (95% CI, 94.9%-99.3%; P = .000; I2 = .0%), and the diagnostic success rate was 87.9% (95% CI, 82.6%-91.7%; P = .000; I2 = .0%). The immunohistochemical success rate was 88.3% (95% CI, 78.7%-93.9%; P = .000; I2 = 3.5%). The rate of adverse events was 7.5% (95% CI, 4.3%-12.7%; P = .00; I2 = 7.2%), and bleeding was the most common adverse event. CONCLUSION: SINK biopsy is a safe diagnostic procedure with a high technical and diagnostic success in patients with GI SET. Further randomized controlled trials and direct comparison studies are needed to validate these findings.

Safety and efficacy of EUS-guided ablation of pancreatic lesions with ethanol versus ethanol with paclitaxel: A systematic review and meta-analysis.

Background and Objectives: EUS-guided ethanol ablation has emerged as an alternative method for pancreatic lesions. Recently, paclitaxel was added to ethanol to assess ablative effects in pancreatic lesions. We performed a systematic review and meta-analysis on EUS-guided ethanol ablation (EUS E) versus EUS-guided ethanol with paclitaxel (EUS EP) ablation for the management of pancreatic lesions. Methods: Comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, and Web of Science databases (from inception to May 2020). The primary outcome evaluated complete ablation of the lesions radiologically and the secondary outcome evaluated adverse events (AEs). Results: Fifteen studies on 524 patients were included in our analysis. The pooled complete ablation rate was 58.89% (95% confidence interval (CI) = 38.72-77.80, I2 = 91.76%) and 55.99% (95% CI = 44.66-67.05, I2 = 0) in the EUS E and EUS EP groups (P = 0.796), respectively. The pooled AE rates were 13.92% (95% CI = 4.71-26.01, I2 = 83.43%) and 31.62% (95% CI = 3.36-68.95, I2 = 87.9%) in the EUS E and EUS EP groups (P = 0.299), respectively. The most common AE was abdominal pain at 7.27% (95% CI = 1.97-14.6, I2 = 68.2%) and 12.44% (95% CI = 0.00-39.24, I2 = 81.1%) in the EUS E and EUS EP groups (P = 0.583), respectively. Correlation coefficient (r) was ‒0.719 (P = 0.008) between complete ablation and lesion size. Conclusion: Complete ablation rates were comparable among both groups. AE rates were higher in the EUS EP group. Further randomized controlled trials are needed to validate our findings.

Gastric Siderosis Due to Oral Ferrous Sulfate Supplements.

Gastric siderosis is the deposition of excess amount of iron from oral ferrous sulfate supplements to the gastric mucosa. It is an often overlooked entity in the literature and can be related to symptoms such as dyspepsia, nausea, and melena through mucosal injury. Different etiologies of gastric siderosis display distinct histopathological patterns. Pattern B, which is most commonly associated with oral iron supplements, is seen when iron is deposited in the extracellular space of the lamina propria. It is crucial to consider gastric siderosis as a potential diagnosis in symptomatic patients and to evaluate the necessity of oral ferrous sulfate supplements.

A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplantation in the Treatment of Hepatic Encephalopathy and Clostridioides difficile Infection in Patients With Cirrhosis.

The microbiome of the human gut and liver coexists by influencing the health and disease state of each system. Fecal microbiota transplantation (FMT) has recently emerged as a potential treatment for conditions associated with cirrhosis, such as hepatic encephalopathy and recurrent/refractory Clostridioides difficile infection (rCDI). We have conducted a systematic review of the safety and efficacy of FMT in treating hepatic encephalopathy and rCDI. A literature search was performed using variations of the keywords "fecal microbiota transplant" and "cirrhosis" on PubMed/MEDLINE from inception to October 3, 2021. The resulting 116 articles were independently reviewed by two authors. Eight qualifying studies were included in the systematic review. A total of 127 cirrhotic patients received FMT. Hepatic encephalopathy was evaluated by cognitive tests, such as the Psychometric Hepatic Encephalopathy Score (PHES) and EncephalApp Stroop test. Not only was there an improvement in the cognitive performance in the FMT cohort, but the improvement was also maintained throughout long-term follow-up. In the treatment of rCDI, the FMT success rate is similar between cirrhotic patients and the general population, although more than one dose may be needed in the former. The rate of serious adverse events and adverse events in the cirrhotic cohort was slightly higher than that in the general population but was low overall. We found evidence that supports the therapeutic potential and safety profile of FMT to treat hepatic encephalopathy and rCDI in cirrhotic patients. Further research will be beneficial to better understand the role of FMT in cirrhosis.

Intrapulmonary Gallstones and Pleuro-Biliary Fistula Formation Due to Complication From Prior Cholecystectomy: A Case Report and Literature Review.

Intrapulmonary gallstones and the formation of pleuro-biliary fistula is a rare complication of laparoscopic cholecystectomy. The stones are most commonly found in the right lower lobe of the lungs. The symptoms tend to be insidious in nature and can manifest as hemoptysis, irritating cough, and cholelithoptysis years after the procedure. The stones can be removed through lobectomy or may also be treated non-invasively with antibiotics only. Here, we describe a case of a patient who developed hemoptysis and was found to have intrapulmonary gallstones from laparoscopic cholecystectomy and subsequent fistula formation.

A comparison of balloon- versus stent-based approach for dominant strictures in primary sclerosing cholangitis: a meta-analysis.

Background: Approximately 10-62% of patients with primary sclerosing cholangitis (PSC) will develop dominant strictures at some point during their disease. Because of the paucity of available data, optimal endoscopic therapeutic strategies remain unclear. We performed a systematic review and meta-analysis of endoscopic balloon dilation vs. balloon dilation plus stenting of dominant strictures in PSC. Methods: A comprehensive literature search from inception to November 2020 was performed. Primary outcomes were clinical and technical success. Secondary outcomes reported were adverse events (AE). Clinical success was defined in most studies as improvement in symptoms such as fever, abdominal pain, pruritus, fatigue and/or liver enzymes. The statistical analysis was done using comprehensive meta-analysis (CMA Version 3). Results: The technical success rates for balloon and balloon plus stent were 96.8% and 91.9%, respectively. The clinical success rates for balloon and balloon plus stent were 86.5% and 70.8%, respectively. The overall AE rates for balloon and balloon plus stent were 11.2% and 26.9%, respectively. Other AE rates in balloon and balloon plus stent were cholangitis (4.8% vs. 11.4%), bile duct perforation (1.3% vs. 1.6%), post-procedural pancreatitis (2.2% vs. 9.8%), and bleeding (1.5% vs. 1.2%), respectively. Low to considerable heterogeneity was noted in our meta-analysis. Conclusions: Balloon dilation appears to be superior in terms of clinical and technical successes, with overall lower rates of AE compared to balloon dilation plus stenting for the management of PSC dominant strictures. Further trials are needed to validate our findings.

Endo-sponge in management of anastomotic colorectal leaks: a systematic review and meta-analysis.

Background and study aims Following colorectal surgery, anastomotic dehiscence and leak formation has an incidence of 2 % to 7 %. Endo-SPONGE has been applied in the management of anastomatic leaks (ALs) after colorectal surgery. This is the first systematic review and meta analysis to evaluate the efficacy and safety of Endo-SPONGE in the management of colorectal ALs. Patients and methods The primary outcomes assessed were the technical and clinical success of Endo-SPONGE placement in colorectal ALs. The secondary outcomes assessed were the overall adverse events (AEs) and the AE subtypes. Pooled estimates were calculated using random-effects models with 95 % confidence interval (C. I.). The statistical analysis was done using STATA v16.1 software (StataCorp, LLC College Station, Texas, United States). Results The analysis included 17 independent cohort studies with a total of 384 patients. The rate of technical success was 99.86 % (95 % CI: 99.2 %, 100 %; P  = 0.00; I 2  = 70.69 %) and the calculated pooled rate of clinical success was 84.99 % (95 % CI: 77.4 %, 91.41 %; P  = 0.00; I 2  = 68.02 %). The calculated pooled rate of adverse events was 7.6 % (95 % CI: 3.99 %, 12.21 %; P  = 0.03; I 2  = 42.5 %) with recurrent abscess formation and bleeding being the most common AEs. Moderate to substantial heterogeneity was noted in our meta-analysis. Conclusions Endoscopic vacuum therapy appears to be a minimally invasive, safe, and effective treatment modality for patients with a significant colorectal leak without any generalized peritonitis with high clinical and technical success rates and a low rate of adverse events. Further prospective or randomized controlled trials are needed to validate our findings.

Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer.

Transarterial angiographic embolization is a highly effective, safe treatment for non-variceal upper gastrointestinal bleeding refractory to endoscopic intervention. However, intraluminal coil migration is a possible complication. Coil migration, while usually a self-limiting process, can lead to significant rebleeding. In our case, a patient presented with a life-threatening duodenal ulcer hemorrhage, likely precipitated by intraluminal endovascular coil migration after a recent gastro-duodenal artery embolization. He was successfully managed without endoscopic coil removal and had no additional gastrointestinal bleeding. It is important for endoscopists to be aware of this complication and weigh the risks and benefits of coil removal.

EUS-guided pelvic drainage: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: EUS-guided pelvic abscess drainage (EUS-PAD) is a procedure that utilizes an echoendoscope to visualize an area of interest for needle insertion and placement of a stent, catheter, or both for drainage of the target abscess. The aim of this study was to perform a systematic review and meta-analysis for the safety and efficacy of EUS-PAD. MATERIALS AND METHODS: We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to February 2020). The primary outcomes for this study were the technical and clinical success of EUS-PAD. The secondary outcomes assessed for this study were adverse events of the procedure and subgroup analysis of individual adverse events. RESULTS: Eight studies with a total of 135 patients combined were included in our analysis. The rate of technical success was 100% and the calculated pooled rate of clinical success was 92% (95% confidence interval [CI]: 87%, 98%; P = 0.31; I2 = 15%). The calculated pooled rate of adverse events was 9.4% (±17.9%), with stent migration (5.5 ± 18.06%) being the most common adverse event. CONCLUSION: EUS-PAD offers a viable alternative that can minimize the need for surgical intervention in the drainage of pelvic abscesses. EUS-PAD has also demonstrated long-term clinical success with an acceptable rate of complications.

Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis.

Background and study aims Transoral outlet reduction (TORe) is an endoscopic procedure used in patients with weight gain post Roux-en-Y gastric bypass (RYGB). We performed a systematic review and meta-analysis to evaluate the efficacy and safety of TORe with a full-thickness suturing device for treating patients with weight regain after RYGB. Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to March 2020). The primary outcomes assessed were technical success, absolute weight loss (AWL) and percent of total weight loss (% TWL) at 3, 6, and 12 months after the procedure. The secondary outcomes assessed were pooled rate of adverse events (AEs), adverse event subtypes and association of size of gastrojejunal anastomosis (GJA) and percent TWL. Results Thirteen studies on 850 patients were included. The pooled rate of technical success was 99.89 %. The absolute weight loss (kg) at 3, 6, and 12 months was 6.14, 10.15, and 7.14, respectively. The percent TWL at 3, 6, and 12 months was 6.69, 11.34, and 8.55, respectively. The pooled rate of AE was 11.4 % with abdominal pain being the most common adverse event. The correlation coefficient (r) was -0.11 between post TORe GJA size and weight loss at 12 months. Conclusion TORe is an endoscopic procedure that is safe and technically feasible for post RYGB with weight gain.