No difference in outcomes with 15 mm vs. 20 mm lumen-apposing metal stents for endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a meta-analysis.

BACKGROUND/AIMS: We compared outcomes between use of 15 vs. 20 mm lumen-apposing metal stents (LAMSs) in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction. METHODS: Databases were queried for studies that used LAMS for EUS-GE to relieve gastric outlet obstruction, and a proportional meta-analysis was performed. RESULTS: Thirteen studies were included. The 15 mm and 20 mm LAMS had pooled technical success rates of 93.2% (95% confidence interval [CI], 90.5%-95.2%) and 92.1% (95% CI, 68.4%-98.4%), clinical success rates of 88.6% (95% CI, 85.4%-91.1%) and 89.6% (95% CI, 79.0%-95.1%), adverse event rates of 11.4% (95% CI, 8.1%-15.9%) and 14.7% (95% CI, 4.4%-39.1%), and reintervention rates of 10.3% (95% CI, 6.7%-15.4%) and 3.5% (95% CI, 1.6%-7.6%), respectively. Subgroup analysis revealed no significant differences in technical success, clinical success, or adverse event rates. An increased need for reintervention was noted in the 15 mm stent group (pooled odds ratio, 3.59; 95% CI, 1.40-9.18; p=0.008). CONCLUSION: No differences were observed in the technical, clinical, or adverse event rates between 15 and 20 mm LAMS use in EUS-GE. An increased need for reintervention is possible when using a 15 mm stent compared to when using a 20 mm stent.

Food as Medicine: How to Influence the Microbiome and Improve Symptoms in Patients with Irritable Bowel Syndrome.

PURPOSE OF REVIEW: This review highlights effects of dietary interventions on the gut microbiome and gastrointestinal symptoms in those with irritable bowel syndrome (IBS). RECENT FINDINGS: It is hypothesized that gut dysbiosis factors into the pathophysiology of IBS. Various diets that influence the microbiome and intestinal physiology may have therapeutic properties. At present, data suggests that implementation of personalized dietary interventions have a mixed, but overall positive effect on the gut microbiome and IBS symptoms. The effect of dietary modification on the gut microbiome and GI symptoms in patients with IBS is a topic that has garnered interest due to the increasing prevalence of IBS and heightened awareness of the importance of gut health. The composition of the gut microbiome may be modulated by promoting fiber intake and implementation of exclusionary diets and dietary supplements; however, additional studies are needed to provide evidence-based guidelines in this patient population.

Intragastric Balloon Significantly Improves Metabolic Parameters at 6 Months: a Meta-Analysis.

INTRODUCTION: It is estimated that by 2030, 38% of the world population will be overweight, and another 20% will be people with obesity. Intragastric balloons (IGBs) are an option in conjunction with lifestyle modification for the treatment of obesity. We sought to investigate the effects of IGB therapy on hemoglobin A1c (A1c), systolic and diastolic blood pressure (SBP, DBP), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides (TGs). METHODS: PubMed, Embase, and Google Scholar were queried through November 2021 to identify studies that evaluated the effects of IGB therapy on selected variables at 6 months. A total of 17 studies and 1198 patients met inclusion criteria. Results were pooled using a random-effects model. RESULTS: At 6-month post-IGB insertion, patients had a significant reduction in A1c (mean difference (MD): - 0.62, 95% confidence interval (CI): - 0.884 to - 0.355, p < 0.001), SBP (MD: - 8.39, 95% CI: - 11.39 to - 5.386, p < 0.001), DBP (MD: - 5.807, 95% CI: - 8.852 to - 2.76, p < 0.001), TC (MD: - 9.189, 95% CI: - 15.763 to - 2.616, p = 0.006), LDL (MD: - 5.20, 95% CI: - 9.05 to - 1.35, p = 0.008), and TGs (MD: - 25.35, 95% CI: - 40.30 to - 10.10, p = 0.001). There was no significant difference in HDL (MD: 1.245, 95% CI: - 0.11 to 2.60, p = 0.071). CONCLUSIONS: Our meta-analysis suggests that IGB therapy is associated with improvements in insulin resistance, blood pressure, and dyslipidemia at 6 months. The results of this analysis suggest that IGB placement can be a viable treatment option to improve important metabolic parameters beyond weight loss alone.

Dietary Intake and Systemic Inflammation: Can We Use Food as Medicine?

PURPOSE OF REVIEW: This review summarizes the current literature regarding the association between diet and systemic inflammation. RECENT FINDINGS: Data in humans suggests that consumption of plant-based nutrients is associated with a reduction in systemic inflammation, while consumption of red meat and excessive dairy has the opposite effect and may increase risk of acute flares in those that suffer from certain chronic diseases like inflammatory bowel disease or psoriasis and certain cancers. There is a known association between diet and systemic inflammation; thus, we recommend that clinicians discuss plant-based, whole food diets with patients, particularly those that suffer from chronic inflammatory diseases as an adjunct treatment for these conditions. Future research should evaluate whether adherence to these types of diets is sustainable in the long term and how these changes affect important quality of life concerns.

Outcomes of upper endoscopy screening in Lynch syndrome: a meta-analysis.

BACKGROUND AND AIMS: Lynch syndrome (LS) predisposes affected individuals to a high lifetime risk of malignancies, including colorectal, endometrial, gastric, and duodenal cancers. The role of upper GI (UGI) cancer screening in LS has been uncertain, but recent studies have evaluated its utility. METHODS: Databases were queried through December 2021 to identify studies that examined upper endoscopy screening in LS using EGD. Mantel-Haenszel pooled odds ratios and 95% confidence intervals (CIs) for outcomes were constructed using a random-effects model to identify pooled odds of endoscopic findings in persons with LS. Event rates for detection of gastric and duodenal cancers, high-risk lesions, and clinically actionable findings were calculated. Statistical heterogeneity was assessed using the I2 statistic. RESULTS: Nine studies were identified with 2356 LS patients undergoing approximately 7838 EGDs. In total, 47 LS-associated UGI cancers (18 gastric and 29 duodenal cancers), 237 high-risk lesions, and 335 clinically actionable findings were identified. The pooled event rate for detection of any UGI cancer, high-risk lesions, and clinically actionable findings during screening were .9% (95% CI, .3-2.1; I2 = 89%), 4.2% (95% CI, 1.6-10.9; I2 = 98%), and 6.2% (95% CI, 2.2-16.5; I2 = 99%), respectively. There was no difference between LS-associated gene and gastric or duodenal cancer detection. CONCLUSIONS: In LS, there is evidence that endoscopic screening detects UGI cancers, precancerous lesions, and other clinically actionable findings that favor its use as a part of cancer risk management in LS.

"Infiltrative" Versus "Mass-Forming" Pancreatic Cancer: A New Radiological Classification System for Pancreatic Head Ductal Carcinoma and Its Pathological Correlation.

Purpose: Resectability in localized pancreatic ductal adenocarcinoma (PDAC) is deemed through radiological criteria. Despite initial evaluation classifying tumors as "resectable," they often have ill-defined borders that can result in more extensive cancer than predicted on final pathology analysis. We attempt to categorize these tumors radiologically and define them as "infiltrative" and contrast them to more well-defined or "mass-forming" tumors and assess their correlation with surgical oncological outcomes. We hypothesize that mass-forming lesions will result in fewer positive resection margins. Methods: Patients diagnosed with PDAC of the head of the pancreas and who underwent subsequent curative intent resection between 2016 and 2018 were included. A retrospective chart review of patients was conducted and computed tomography images at the time of diagnosis were reviewed by two radiologists and scored as "mass forming" or "infiltrative" using a newly developed classification system. These classifications were then correlated with margin status. Results: Sixty-eight consecutive pancreatoduodenectomies performed for PDAC from 2016 to 2018 were identified. After screening, 54 patients were eligible for inclusion. Radiologically defined mass-forming lesions had a trend toward a lower rate of positive resection margins (35.7% vs. 50.0%; p = 0.18), specifically the bile duct margin and pancreas margin as well as an overall larger size (4.03 cm vs. 3.25 cm, p = 0.02) compared with infiltrative lesions. Conclusion: We propose a new radiological definition of PDAC into "mass forming" and "infiltrative," a nomenclature that resonates with other tumor sites. Infiltrative lesions trended toward a higher rate of positive resection margins. This classification may help tailor therapy for infiltrative tumors toward a neoadjuvant approach even if they appear resectable.

Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

BACKGROUND/AIMS: Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. METHODS: One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: "Trainees," "Consultants group 1" (performed >75 ERCPs per year), and "Consultants group 2" (performed >100 ERCPs per year). RESULTS: Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77-0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74-0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69-0.95). CONCLUSION: This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

Impact of Obesity on Inflammatory Bowel Disease.

PURPOSE OF REVIEW: This review highlights recent work that evaluates the impact of obesity on inflammatory bowel disease (IBD) pathogenesis and management. RECENT FINDINGS: The impact of obesity on IBD prevalence, clinical course, and management, has been studied and described more so in recent years. Studies have shown that obesity increases IBD disease activity, leads to longer hospitalization courses, and increases the likelihood of the development of extraintestinal manifestations. Recent evidence has also suggested that obese IBD patients have a higher frequency of extended steroid treatment and increased use of antibiotics compared to non-obese IBD patients. The effect of obesity on patients with IBD is a topic that has garnered widespread interest in the last decade due to the increasing prevalence of both diseases. To date however, although there are still many unanswered questions. It is quite clear that obesity, and more specifically, visceral adiposity, affects numerous IBD-related outcomes in regard to pathogenesis, extra-intestinal manifestations, response to medical and surgical therapies, hospital length of stay, healthcare-related costs, and health-related quality of life. Future studies should include larger patient populations and evaluate additional factors that are altered in those with obesity including the gut microbiome, dietary patterns, and whether weight loss and/or degree of weight loss impact clinical outcomes.

Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis.

BACKGROUND: We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis. METHODS: A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel-Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots. RESULTS: Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22-1.62, P = 0.31) between LR and NS. I2 indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission. CONCLUSIONS: This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.

Endoscopic Ultrasound-Guided Biliary Interventions in Liver Disease.

If endoscopic retrograde cholangiopancreatography (ERCP) fails in cases of biliary obstruction and jaundice, percutaneous drains have been traditionally the current second-line option. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) with choledocoduodenostomy or hepaticogastrostomy is alternative modality that have shown equivalent or better technical and clinical success compared with percutaneous drainage. Similarly, EUS-guided gallbladder drainage has emerged as a therapeutic option in acute cholecystitis as well. Furthermore, EUS-BD avoids some of the pitfalls of percutaneous drainage. Current research in EUS-BD involves optimizing devices to improve technical and clinical success. In centers with advanced endoscopists trained in these procedures, EUS-BD is an excellent second-line modality.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis.

BACKGROUND/OBJECTIVE: Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. RESULTS: Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay. CONCLUSIONS: Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Unrecognized anemia after whipple - should we learn from gastric bypass?

INTRODUCTION: Several pathophysiologic changes after the Whipple procedure have been well described, but anemia has not. Post-surgical changes can impede micronutrient absorption. We hypothesize that patients post-pancreatoduodenectomy suffer from iron deficiency anemia. METHODS: Patients who underwent a pancreatoduodenectomy from 2016 to 2018 were retrospectively evaluated. Preoperative, intraoperative, and postoperative data, including hemoglobin (Hb) levels and mean corpuscular volume (MCV) as well as therapies with chemoradiation, iron, and/or B12 were collected at 1-, 3-, 6-, and 12-months after surgery. RESULTS: The dataset included 74 patients (median age: 64 years). Mean preoperative Hb and MCV were 11.7 ± 1.9 g/dl and 90.1 ± 7.3 fl, respectively. Significant changes in Hb were noted at 1 and 6 months (11.7 vs 10.9, p = 0.01 and 11.7 vs 11.3, p = 0.003, respectively), and in MCV were noted at 6 and 12 months (90.1 vs 94.6, p = 0.008 and 90.1 vs. 93.7, p = 0.02, respectively). CONCLUSIONS: All patients remained anemic after pancreatoduodenectomy. This was not linked to chemotherapy. Iron and vitamin B12 supplementation, given in a minority, did not ameliorate the anemia. Future studies should investigate this lack of aid, as nutrient supplementation may be an important change in the standard of care of these patients.

Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes.

BACKGROUND: Endoscopic techniques can provide an alternative to surgery in the management of post-bariatric surgery complications such as leaks, strictures, fistulas, and erosion of transgastric and adjustable gastric bands. Endoscopically placed stents can also be used to manage gastric perforations secondary to NSAIDS or perforated marginal ulcers following gastric bypass surgery. Additionally, stents can be used in conjunction with operative intervention to decrease the risk of more deleterious complications that could require additional operations. OBJECTIVES: The objective of this report is to describe our private practice experience in managing bariatric procedure complications with fully covered endoscopic stents. We present the algorithm we use in the application of endoscopic stents in the management of complications following bariatric surgery. SETTING: Private practice, Single provider, Tertiary Referral Center, USA METHODS: Data for all patients who underwent endoscopic stent placement for complications after various bariatric surgeries (Roux-en-Y gastric bypass, gastric sleeve, lap band, and vertical banded gastroplasty) performed by several different surgeons between July 2015 and December 2018 at a single private practice were retrospectively reviewed. Patient's medical history, perioperative information, stent placement details, outcomes, and subsequent interventions were reviewed and analyzed. RESULTS: Thirty-five patients who were treated with endoscopic stents after bariatric surgery were identified. Complications after bariatric surgery treated with stenting included staple line leaks, anastomotic leaks, strictures, marginal ulcer perforations, gastrogastric fistula, and lap band erosion repairs. Mean duration of each stent round also varied. Resolution occurred in 33 patients (94.3%). Stent migration occurred in seven patients (20%) and in eight of 51 stents placed (15.7%). Two patients ultimately required revision surgery, though only one was related to stent (2.9%). CONCLUSIONS: Our findings suggest that foregut stents deployed according to our algorithm can facilitate healing of anastomotic leaks, staple line leaks, and marginal ulcer perforations. Furthermore, stent placement can also bolster tenuous repairs of band erosion sites, repairs staple line failure, and manages leaks at band erosion repair sites. Endoscopic stents can also be utilized to augment both balloon and savory dilation of gastric anastomoses and gastric sleeve strictures. Stents should be clipped proximally and distally to minimize the risk of migration.