EUS-guided gastroenterostomy versus enteral stenting for gastric outlet obstruction: Systematic review and meta-analysis.

Background and study aims Endoscopic and surgical techniques have been utilized for palliation of gastric outlet obstruction (GOO). Enteral stenting (ES) is an established technique with high clinical success and low morbidity rate. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel approach that aims to provide sustained palliation of GOO. We conducted a comprehensive review and meta-analysis to evaluate the effectiveness in terms of clinical and technical success, as well as the safety profile of EUS-GE and ES. Methods We searched multiple databases from inception through July 2020 to identify studies that reported on safety and effectiveness of EUS-GE in comparison to ES. Pooled rates of technical success, clinical success, and adverse events (AEs) were calculated. Study heterogeneity was assessed using I 2 % and 95 % confidence interval. Results Five studies including 659 patients were included in our final analysis. Pooled rate of technical and clinical success for EUS-GE was 95.2 % (CI 87.2-.98.3, I 2  = 42) and 93.3 % (CI 84.4-97.3, I 2  = 59) while for ES it was 96.9 % (CI 90.9-99, I 2  = 64) and 85.6 % (CI 73-92.9, I 2  = 85), respectively. Pooled rate of re-intervention was significantly lower with EUS-GE i. e. 4 % (CI 1.8-8.7, I 2  = 35) compared to ES, where it was 23.6 % (CI 17.5-31, I 2  = 35), p = 0.001 . Pooled rates of overall and major AEs were comparable between the two techniques. Conclusion EUS-GE is comparable in terms of technical and clinical effectiveness and has a similar safety profile when compared to ES for palliation of GOO.

Adenoma and polyp detection rates during insertion versus withdrawal phase of colonoscopy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Colonoscopy is the preferred modality for colorectal cancer screening because it has both diagnostic and therapeutic capabilities. Current consensus states that colonoscopy should be performed with initial rapid passage of the instrument to the cecum, followed by thorough evaluation for and removal of all polyps during a deliberate slow withdrawal. Reports have suggested that polyps that are seen but not removed during insertion are sometimes quite difficult to find during withdrawal. METHODS: We performed a comprehensive literature search of several major databases (from inception to March 2020) to identify randomized controlled trials comparing inspection and polypectomy during the insertion phase as opposed to the traditional practice of inspection and polypectomy performed entirely during the withdrawal phase. We examined differences in terms of adenoma detection rate (ADR), polyps detected per patient (PDPP), cecal intubation time (CIT), withdrawal time, and total procedure time. RESULTS: Seven randomized controlled trials, including 3834 patients, were included in our final analysis. The insertion/withdrawal cohort had 1951 patients and the withdrawal-only cohort 1883 patients. Pooled odds of adenoma detection in the insertion/withdrawal cohort was .99 (P = .8). ADR was 47.2% in the insertion/withdrawal cohort and 48.6% in the withdrawal-only cohort. Although total procedure and withdrawal times were shorter in the insertion/withdrawal cohort, PDPP in both cohorts were not statistically significant (1.4 vs 1.5, P = .7). CONCLUSIONS: Additional inspection and polypectomy during the insertion and withdrawal phases of colonoscopy offer no additional benefit in terms of ADR or PDPP.

Comparison of EUS-guided conventional smear and liquid-based cytology in pancreatic lesions: A systematic review and meta-analysis.

Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) has limitations of inadequate sampling and false-negative results for malignancy. It has been performed using conventional smear (CS) cytology with rapid on-site evaluation (ROSE) with reasonable diagnostic accuracy. An alternative to ROSE is liquid-based cytology (LBC). Commonly used LBC techniques include precipitation-based (SurePath™) and filtration-based (ThinPrep ® , CellPrep ® ). Data regarding the diagnostic efficacy of LBC compared with CS are limited. Methods Multiple databases were searched through March 2020 to identify studies reporting diagnostic yield of EUS-guided CS and LBC in pancreatic lesions. Pooled diagnostic odds and rates of performance for the cytologic diagnoses of benign, suspicious, and malignant lesions were calculated. Diagnostic efficacy was evaluated by pooled rates of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results Nine studies with a total of 1308 patients were included in our final analysis. Pooled diagnostic odds of CS cytology were 1.69 (CI 1.02-2.79) and 0.39 (CI 0.19-0.8) for malignant lesions when compared to filtration-based and precipitation-based LBC techniques, respectively. For CS, precipitation-based and filtration-based LBC, pooled diagnostic accuracy was 79.7 %, 85.2 %, 77.3 %, sensitivity was 79.2 %, 83.6 %, 68.3 %, and specificity was 99.4 %, 99.5 %, 99.5 %, respectively. Conclusions The precipitation-based LBC technique (SurePath™) had superior diagnostic odds for malignant pancreatic lesions compared with CS cytology in the absence of ROSE. It showed superior accuracy and sensitivity, but comparable specificity and PPV. Diagnostic odds of CS cytology in the absence of ROSE were superior to the filtration-based LBC technique (ThinPrep ® , Cellprep ® ) for diagnosing malignant pancreatic lesions.

A Dire Presentation of Diabetic Ketoacidosis with "Black Esophagus.

Acute esophageal necrosis (AEN) is a rare life-threatening illness that is being increasingly recognized in the past two decades. It usually develops in the setting of severe systemic illness due to a combination of tissue hypoperfusion, impaired mucosal defenses and gastric reflux. The most common presentation is with upper gastrointestinal bleeding complicating diabetic ketoacidosis, sepsis, pancreatitis, trauma, shock, renal failure, alcohol poisoning or other states of hemodynamic compromise. The classic finding on endoscopy is of necrosis of the distal esophagus with a sharp transition to normal gastric mucosa at the gastroesophageal junction. Management is aimed at treating the underlying insult and providing supportive care. We report a case of "black esophagus" complicating an episode of diabetic ketoacidosis in a 34-year-old male. The patient was treated with broad-spectrum antibiotics, antifungals and a high-dose proton pump inhibitor in addition to the treatment of ketoacidosis. No serious acute or long-term complication was identified and follow-up endoscopy showed resolution of necrosis.

Persistent Cerebrospinal Fluid Leukocytosis: Could this be Idiopathic Intracranial Hypertension?

A 37-year-old female, a known epileptic, presented to the neurology clinic with a seven-day history of persistent bilateral headache not improving with analgesics. Her neurological and systemic examinations were unremarkable except for right optic disc edema. Magnetic resonance imaging (MRI) brain and magnetic resonance venography (MRV) were normal but her cerebrospinal fluid (CSF) opening pressure was 280 mm of water with a CSF white cell count of 214. The patient showed improvement following treatment with intravenous antibiotics and acyclovir. She returned a week later with double vision and blurring in both eyes. Examination showed bilateral sixth nerve palsies and bilateral optic disc edema with left fundal hemorrhages. The spinal tap was repeated again, which showed a CSF opening pressure of 500 mm of water and the white cell count was 48. Extensive investigations for etiologies were mostly unrevealing. The patient was started on acetazolamide and topiramate combined with a large-volume therapeutic CSF tap. She continued to improve subsequently and was at the baseline functional state at three months, with complete resolution of hemorrhages and optic disc edema. Idiopathic intracranial hypertension (IIH) may present with persistent abnormal CSF with a high white cell count. Therefore, this must be diagnosed with caution, as it may be misdiagnosed and wrongly treated for other causes.