Publications by authors named "Douglas G Adler"

400 Publications

Early Colonoscopy Does Not Affect 30-Day Readmission After Lower GI Bleeding: Insights from a Nationwide Analysis.

Dig Dis Sci 2021 Sep 14. Epub 2021 Sep 14.

Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA.

Introduction: Lower gastrointestinal bleeding (LGIB) is one of the most common indications for hospital admission. The current standard of care for patients admitted with LGIB includes colonoscopy. The aims of this study are to define the rate of readmission in patients with LGIB and to determine whether early colonoscopy within the first 24 h after admission impacts the rate of readmission in these patients.

Methods: We performed a retrospective cohort study on data obtained from the Nationwide Readmission Database and identified patients admitted with lower GI bleed using ICD-10 codes. The primary outcome was 30-day all-cause readmission, and one of our secondary outcomes was the impact of early colonoscopy on 30-day readmission.

Results: We analyzed data from 35,790,513 patients who were admitted for LGIB in 2017. A total of 16.4% of these patients were readmitted within 30 days of discharge, with diverticular bleeding most common diagnosis for readmission. Overall, in-hospital mortality was 1.18% for index admission and 4.44% for readmission. Early colonoscopy did not impact the rate of readmission within 30 days of discharge.

Conclusion: LGIB remains a commonly encountered in clinical practice with a high readmission rate. Mortality is significantly higher during readmission compared to index admission. Early colonoscopy did not impact the 30-day readmission rate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-07243-4DOI Listing
September 2021

Outcomes of Endoscopic Submucosal Dissection for Treatment of Superficial Pharyngeal Cancers: Systematic Review and Meta-Analysis.

Dig Dis Sci 2021 Sep 9. Epub 2021 Sep 9.

Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital, 2525 S Downing St, Denver, CO, 80210, USA.

Background And Aims: Studies evaluating the role of endoscopic submucosal dissection (ESD) in the management of superficial pharyngeal cancers have reported promising results. This meta-analysis evaluates the efficacy and safety of ESD in the management of superficial pharyngeal cancers.

Methods: We reviewed several databases from inception to September 03, 2020, to identify studies evaluating the efficacy and safety of ESD in the management of superficial pharyngeal cancers. Our outcomes of interest were en bloc resection rate, complete resection rate, adverse events, and rates of local recurrence. Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using random-effect model. Heterogeneity was assessed by I statistic. We assessed publication bias by using funnel plots and Egger's test. We conducted meta-regression analysis to explore heterogeneity in analyses.

Results: Ten studies were included in analyses. All studies were from Asia. Pooled rates (95% CI) for en bloc resection and complete resection were 94% (87%, 97%) and 72% (62%, 80%), respectively. The pooled rates (95% CI) for adverse events and local recurrence were 10% (5%, 17%) and 1.9% (0.9%, 4%), respectively. Most of the analyses were limited by substantial heterogeneity. On meta-regression analysis, the heterogeneity was explained by size of tumor and histology. Funnel plots and Egger's test showed no evidence of publication bias.

Conclusions: This meta-analysis including studies from Asian countries demonstrated that ESD is an efficacious and safe option in the management of superficial pharyngeal cancers. More studies and studies from Western countries are needed to further validate these findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-07225-6DOI Listing
September 2021

Endoscopic band ligation in treatment of gastric antral vascular ectasia: a systematic review and meta-analysis.

Gastrointest Endosc 2021 Sep 1. Epub 2021 Sep 1.

Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA. Electronic address:

Background And Aims: Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end.

Methods: We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in treatment of GAVE. Random effects model was used to calculate the pooled rates; I% values and 95% prediction intervals were calculated to assess the heterogeneity.

Results: A total of 10-studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% CI, 62.2-91.7) and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI,10.7-19.4). The pooled mean difference of pre- to post-treatment Hb was 1.5 (95% CI, 0.9-2.2; p=0.001); pre- to post-treatment units of PRBCs transfused was 1.1 (95% CI, 0.4-1.9; p=0.002); and pre- to post-treatment hospital length of stay was 0.5 (95% CI, 0.1-0.9; p=0.01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7).

Conclusion: EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter RCTs comparing EBL and other modalities as initial therapy are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2021.08.017DOI Listing
September 2021

Outcomes among inpatients with cirrhosis and infection in the modern era: results from an analysis of the National Inpatient Sample.

Ann Gastroenterol 2021 Sep-Oct;34(5):721-727. Epub 2021 Jun 14.

Department of Gastroenterology and Hepatology, University of Utah, Salt Lake City UT (Sentia Iriana, Stephanie McDounough, Eduardo Rodriguez Zarate, Douglas G. Adler).

Background: Patients with cirrhosis are at increased risk of infection (CDI). We analyzed outcomes and healthcare utilization in hospitalized cirrhotic patients with CDI.

Methods: The Nationwide Inpatient Sample from 2016-2017 identified 8245 hospitalized patients with a concurrent diagnosis of cirrhosis and CDI. Our primary outcome was in-hospital all-cause mortality. Secondary outcomes were length of stay (LOS), hospitalization charges and costs, shock, sepsis, acute kidney injury (AKI), intensive care unit (ICU) admission, and home discharge.

Results: There was no significant difference in all-cause in-hospital mortality between patients with cirrhosis compared to patients without cirrhosis (adjusted odds ratio [aOR] 1.31, 95% confidence interval [CI] 0.89-1.93; P=0.16). Patients with cirrhosis had a slightly but statistically significantly longer mean LOS (+0.57 days, P=0.001). The adjusted difference in mean hospitalization charges was greater in patients with cirrhosis ($+4094, 95%CI $1080-7108; P=0.008), as was the mean hospitalization cost ($+1349, 95%CI $600-2098; P<0.001). There was no difference in the likelihood of sepsis, ICU admission, or home discharge between the groups. Patients with cirrhosis were significantly less likely to develop AKI (aOR 0.82, 95%CI 0.72-0.93; P=0.003).

Conclusions: Mortality outcomes associated with CDI have improved over time. Patients with cirrhosis continue to exhibit greater LOS and hospital costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20524/aog.2021.0646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375645PMC
June 2021

Comparison of left versus right lateral starting position on colonoscopy: a systematic review and meta-analysis of randomized controlled trials.

Ann Gastroenterol 2021 Sep-Oct;34(5):699-704. Epub 2021 Jun 3.

Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah (Babu P. Mohan, Douglas G. Adler).

Background: Modifying patient position during colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. The left lateral (LL) decubitus starting position is commonly used during colonoscopy. However, reports indicate that other starting positions may offer additional benefit. We aimed to determine if the right lateral (RL) starting position compared to the standard LL starting position could improve outcomes in colonoscopy.

Methods: We searched PubMed, Medline, and EMBASE through June 2020 to identify studies comparing RL and LL starting positions during colonoscopy. The primary outcomes included mean cecal insertion time and cecal intubation rate, and adverse events were assessed by pooling data using a random-effects model expressed in terms of odds ratio (OR), mean difference, and 95% confidence interval (CI).

Results: We identified 5 randomized controlled trials, including 809 participants, that compared LL vs. RL colonoscopy. The pooled OR for cecal intubation rate was 1.3 (95%CI 0.8-2.3; P=0.3). The mean difference in mean cecal insertion time was 0.08 (95%CI -0.09 to 0.26; P=0.4). Heterogeneity between studies was low ( =0%). No complications were reported in either arm of the study. Pain scores assessed using a visual analog scale were comparable among both arms of the study.

Conclusion: The RL starting position for colonoscopy was comparable to the LL and offered no additional benefit in terms of cecal intubation time, intubation rate, or patient discomfort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20524/aog.2021.0639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375655PMC
June 2021

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

Endosc Int Open 2021 Sep 16;9(9):E1342-E1349. Epub 2021 Aug 16.

Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States.

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. 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). 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 %;  = 0.00; I  = 70.69 %) and the calculated pooled rate of clinical success was 84.99 % (95 % CI: 77.4 %, 91.41 %;  = 0.00; I  = 68.02 %). The calculated pooled rate of adverse events was 7.6 % (95 % CI: 3.99 %, 12.21 %;  = 0.03; I  = 42.5 %) with recurrent abscess formation and bleeding being the most common AEs. Moderate to substantial heterogeneity was noted in our meta-analysis. 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1490-8783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367445PMC
September 2021

Celiac Disease Is Associated with Microscopic Colitis in Refractory Cases in Adults: A Systematic Review and Meta-Analysis of Observational Studies.

Dig Dis Sci 2021 Aug 27. Epub 2021 Aug 27.

Department of Gastroenterology, Centura Health, Center for Advanced Therapeutic Endoscopy, Denver, CO, USA.

Background: Microscopic colitis and Celiac disease have been shown to occur concomitantly, but their relationship has yet to be systematically evaluated. Some patients with refractory microscopic colitis may have simultaneous celiac disease, and the converse is also true.

Aims: We performed a systematic review and meta-analysis of observational studies to assess the prevalence and possible association between these two conditions.

Methods: PubMed, Embase, Cochrane, Web of Science, SciELO, and CINAHL Plus were systematically searched through January 26, 2021, to include relevant observational studies assessing the prevalence of microscopic colitis in celiac disease population or vice versa. DerSimonian-Laird approach using random effects was used to pool data and compare outcomes. Pooled prevalence, 95% confidence interval (CI), and p values (where applicable) were calculated.

Results: Five studies (with 2589 patients, age range 39.5-52 years and females 66.6%) and 21 studies (with 7186 patients, age range 46.4-65.8 years and females 76.3%) were included assessing the prevalence of microscopic colitis in refractory celiac disease and celiac disease in refractory microscopic colitis cohort. The overall prevalence was 4.5% (2.6-6.3%) and 6.7% (5.2-8.1%), respectively. Five studies showed higher odds of celiac disease diagnosis in the refractory microscopic colitis population compared to the control group (OR 8.12, CI 4.92-13.41, p < 0.001).

Conclusion: Celiac disease and microscopic colitis are concomitantly prevalent in a subset of population with either refractory diagnosis. Clinicians should explore alternate diagnosis when one condition has been appropriately treated and patients continue to have refractory symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-07232-7DOI Listing
August 2021

Short versus standard esophageal myotomy in achalasia patients: a systematic review and meta-analysis of comparative studies.

Endosc Int Open 2021 Aug 16;9(8):E1246-E1254. Epub 2021 Jul 16.

Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States.

Despite the clinical efficacy of peroral endoscopic myotomy (POEM), postoperative symptomatic gastroesophageal reflux disease (GERD) remains a major concern. While it is known that length of the gastric myotomy affects postoperative GERD, the clinical relevance of variation in esophageal myotomy length is not well known. We performed a systematic review and meta-analysis of studies comparing outcomes of short versus standard myotomy length in patients with achalasia. We searched multiple databases from inception through November 2020 to identify studies that reported on outcomes of achalasia patients who underwent short compared with standard esophageal myotomy. Meta-analysis was performed to determine pooled odds ratio (OR) of clinical success, GERD outcomes, and adverse events with the two techniques. 5 studies with 474 patients were included in the final analysis (short myotomy group 214, standard myotomy group 260). There was no difference in clinical success (OR 1.17, 95 % confidence interval [CI] 0.54-2.52; I2 0 %;  = 0.69), postoperative symptomatic GERD (OR 0.87, 95 %CI 0.44-1.74; I2 29 %;  = 0.70), and overall adverse events (OR 0.52, 95 %CI 0.19-1.38; I2 40 %;  = 0.19), between the two groups. Incidence of postoperative erosive esophagitis as determined by endoscopy was lower in the short myotomy group (OR 0.50, 95 %CI 0.24-1.03; I2 0 %;  = 0.06). Our analysis showed that performing POEM with short esophageal myotomy in achalasia was as safe and effective as standard myotomy, with lower incidence of postoperative erosive esophagitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1490-8493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8383091PMC
August 2021

Endoscopic ampullectomy: Can expert input shape endoscopic practice?

Gastrointest Endosc 2021 Oct 19;94(4):774-775. Epub 2021 Aug 19.

Center for Advanced Therapeutic Endoscopy, Porter Adventist Hospital/PEAK Gastroenterology, Denver, Colorado, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2021.05.030DOI Listing
October 2021

EUS-guided biliary drainage: A realistic perspective.

Endosc Ultrasound 2021 Jul-Aug;10(4):227-229

Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital, Centura Heatlh, Denver, CO, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/EUS-D-21-00173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411561PMC
August 2021

Top ten things to remember when cannulating the bile duct in patients with native papillary anatomy during ERCP (with videos).

Authors:
Douglas G Adler

Gastrointest Endosc 2021 Aug 11. Epub 2021 Aug 11.

Center for Advanced Therapeutic Endoscopy, Centura Health, Porter Adventist Hospital, Denver, Colorado. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2021.08.001DOI Listing
August 2021

Wet- dry-suction techniques for EUS-FNA of solid lesions: A systematic review and meta-analysis.

Endosc Ultrasound 2021 Jul 8. Epub 2021 Jul 8.

Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Hospital, Peak Gastroenterology, Denver, Colorado, USA.

The optimal sampling techniques for EUS-FNA remain unclear and have not been standardized. To improve diagnostic accuracy, suction techniques for EUS-FNA have been developed and are widely used among endoscopists. The aim of this study was to compare wet-suction and dry-suction EUS-FNA techniques for sampling solid lesions. We performed a comprehensive literature search of major databases (from inception to June 2020) to identify prospective studies comparing wet-suction EUS-FNA and dry-suction EUS-FNA. Specimen adequacy, sample contamination, and histologic accuracy were assessed by pooling data using a random-effects model expressed in terms of odds ratio (OR) and 95% confidence interval (CI). Six studies including a total of 418 patients (365 wet suction vs. 377 dry suction) were included in our final analysis. The study included a total of 535 lesions (332 pancreatic lesions and 203 nonpancreatic lesions). The pooled odds of sample adequacy was 3.18 (CI: 1.82-5.54, P = 0.001) comparing wet- and dry-suction cohorts. The pooled odds of blood contamination was 1.18 (CI: 0.75-1.86, P = 0.1). The pooled rate for blood contamination was 58.33% (CI: 53.65%-62.90%) in the wet-suction cohort and 54.60% (CI 49.90%- 59.24%) in the dry-suction cohort (P = 0.256). The pooled odds of histological diagnosis was 3.68 (CI 0.82-16.42, P = 0.1). Very few adverse events were observed and did not have an impact on patient outcomes using either method. EUS-FNA using the wet-suction technique offers higher specimen quality through comparable rates of blood contamination and histological accuracy compared to dry-suction EUS-FNA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/EUS-D-20-00198DOI Listing
July 2021

Endoscopic Management of Ampullary Adenomas in Familial Adenomatous Polyposis Syndrome: A Systematic Review with Pooled Analysis.

Dig Dis Sci 2021 Jul 12. Epub 2021 Jul 12.

Center for Advanced Therapeutic Endoscopy, Centura Health, Porter Adventist Hospital, Denver, CO, USA.

Background: Endoscopic papillectomy is a viable therapy in ampullary lesions. Prior studies have reported on outcomes of sporadic ampullary lesions, and only small cohort studies have reported outcomes associated with familial adenomatous polyposis (FAP) syndrome.

Aims: We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for treating ampullary adenomas in FAP.

Methods: We performed a comprehensive literature search of major databases from inception to May 2020. Studies that included patients with endoscopically resected ampullary lesions and FAP were eligible. The rate of technical success, en bloc resection, piecemeal resection, recurrence, and adverse events was pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval (CI).

Results: Six studies, including a total of 99 patients, were included in our final analysis. Patient age ranged from 28 to 91 years. Pooled technical success was 90.3% (CI 76.9-96.3%, I = 31%). Rate of en bloc resection was 60.6% (CI 47.9-72.0%, I = 0%). Recurrence rate was 25.4% (5.7-65.9%, I = 82%). The post-procedural pancreatitis rate was 14.7% of which 68% (51 of 75) utilized prophylactic pancreatic stenting. Other adverse events included bleeding (9.2%) and perforation (4%).

Conclusion: Endoscopic papillectomy offers high technical success but remains challenging in patients with FAP, particularly due to high recurrence rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-07132-wDOI Listing
July 2021

Management of early gastric cancer meeting criteria for endoscopic resection: US population-based study.

Endosc Int Open 2021 Jul 17;9(7):E989-E993. Epub 2021 Jun 17.

Division of Gastroenterology and Hepatology, Utah University, Salt Lake City, Utah, United States.

The goal of this study was to assess surgical resection (SR) of early gastric cancer (EGC) fitting Japanese Gastric Cancer Association (JGCA) endoscopic resection (ER) criteria. We analyzed EGC data from the national Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. A total of 2219 EGC cases were identified (1074 T1a and 1145 T1b). Of them, 409 met absolute criteria, 219 met expanded 1, 529 expanded 2, and 229 expanded 3. 259 lesions were treated endoscopically while 1007 were surgically resected (20.5 % vs 79.5 %,  = 0.0001). Temporal analysis showed that the frequency of ER steadily increased while SR proportionally decreased during the study period. Cox proportion regression analysis adjusting for confound variables (including age, gender, and race) showed no significant difference in the risk of mortality following either surgery or endoscopy. EGC can be safely treated with ER. However, EGC meeting JGCA ER criteria is largely treated with SR in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1478-3281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211475PMC
July 2021

Lactated Ringer's vs normal saline for acute pancreatitis: An updated systematic review and meta-analysis.

Pancreatology 2021 Jun 18. Epub 2021 Jun 18.

Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA. Electronic address:

Introduction: Recent studies have evaluated and compared the efficacy of normal saline (NS) and lactated Ringer's (LR) in reducing the severity of acute pancreatitis (AP) and improving outcomes such as length of stay, the occurrence of the systemic inflammatory response syndrome (SIRS), ICU admission and mortality. We performed an updated systematic review and meta-analysis of the available studies to assess the impact of these fluids on outcomes secondary to AP.

Methods: We systematically searched the following databases: PubMed/Medline, Embase, Cochrane, and Web of Science through February 8th, 2021 to include randomized controlled trials (RCTs) and cohort studies. Random effects model using DerSimonian-Laird approach was employed and risk ratios (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated for binary and continuous outcomes, respectively.

Results: 6 studies (4 RCTs and 2 cohort studies) with 549 (230 in LR and 319 in NS) were included. The overall mortality (RR: 0.73, CI: 0.31-1.69) and SIRS at 24 h (RR: 0.69, CI: 0.32-1.51) was not significantly different. The overall ICU admission was lower in LR group compared to NS group (RR: 0.43, CI: 0.22-0.84). Subgroup analysis of RCTs demonstrated lower length of hospital stay for LR group compared to NS group (MD: 0.77 days, CI: 1.44 -0.09 days).

Conclusion: Our study demonstrated that LR improved outcomes (ICU admission and length of stay) in patients with AP compared to NS. There was no difference in rate of SIRS development and mortality between LR and NS treatments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.pan.2021.06.002DOI Listing
June 2021

EUS-directed transgastric ERCP: A first-line option for ERCP following Roux-en-Y gastric bypass.

Endosc Ultrasound 2021 May-Jun;10(3):151-153

Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Hospital, Peak Gastroenterology, Denver, Colorado, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/eus.eus_148_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248302PMC
June 2021

Direct Endoscopic Necrosectomy With and Without Hydrogen Peroxide for Walled-off Pancreatic Necrosis: A Multicenter Comparative Study.

Am J Gastroenterol 2021 04;116(4):700-709

1Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; 2Division Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA; 3Division Gastroenterology and Hepatology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; 4Borland-Groover Clinic, Jacksonville, Florida, USA; 5Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA; 6Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA; 7Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania, USA; 8Division of Gastroenterology, Hepatology and Nutrition, The Ohio state University Wexner Medical Center, Columbus, Ohio, USA; 9Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA; 10Biostatistics & Bioinformatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA; 11Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Introduction: Endoscopic necrosectomy has emerged as the preferred treatment modality for walled-off pancreatic necrosis. This study was designed to evaluate the safety and efficacy of direct endoscopic necrosectomy with and without hydrogen peroxide (H2O2) lavage.

Methods: Retrospective chart reviews were performed for all patients undergoing endoscopic transmural management of walled-off pancreatic necrosis at 9 major medical centers from November 2011 to August 2018. Clinical success was defined as the resolution of the collection by imaging within 6 months, without requiring non-endoscopic procedures or surgery.

Results: Of 293 patients, 204 met the inclusion criteria. Technical and clinical success rates were 100% (204/204) and 81% (166/189), respectively. For patients, 122 (59.8%) patients had at least one H2O2 necrosectomy (H2O2 group) and 82 (40.2%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group: 106/113 (93.8%) vs 60/76 (78.9%), P = 0.002. On a multivariate analysis, the use of H2O2 was associated with higher clinical success rate (odds ratio 3.30, P = 0.033) and earlier resolution (odds ratio 2.27, P < 0.001). During a mean follow-up of 274 days, 27 complications occurred. Comparing procedures performed with and without H2O2 (n = 250 vs 183), there was no difference in post-procedure bleeding (7 vs 9, P = 0.25), perforation (2 vs 3, P = 0.66), infection (1 vs 2, P = 0.58), or overall complication rate (n = 13 [5.2%] vs 14 [7.7%], P = 0.30).

Discussion: H2O2-assisted endoscopic necrosectomy had a higher clinical success rate and a shorter time to resolution with equivalent complication rates relative to standard necrosectomy.See the visual abstract at http://links.lww.com/AJG/B714.(Equation is included in full-text article.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/ajg.0000000000000987DOI Listing
April 2021

Endoscopy in Patients With Surgically Altered Anatomy.

Am J Gastroenterol 2021 04;116(4):657-665

1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA; 2Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA.

A comprehensive understanding of gastrointestinal anatomy is essential for performance of any endoscopic procedure. Surgical approaches to therapy have become increasingly common in the past decade, which has resulted in a substantial proportion of patients with surgically altered anatomy who require endoscopy. In parallel with the obesity epidemic, bariatric surgery for obesity management has been widely adopted. In response to these trends, gastroenterologists must become familiar with patient anatomy after these surgical interventions and understand the implications of this altered anatomy on the current array of available endoscopic modalities for diagnosis and therapy. This review describes the range of surgically altered anatomy commonly encountered in the upper gastrointestinal tract. For each foregut location-esophagus, stomach, and small bowel-we describe indications for and specific details of the range of common surgical approaches affecting this regional anatomy. We then provide an endoscopic roadmap through the altered anatomy resulting from these surgical interventions. Finally, we address the impact of postsurgical anatomy on performance of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, with guidance surrounding how to successfully execute these procedures. Evolution of endoscopic approaches over time might be expected to enhance the safety and efficacy of these interventions in patients with surgically altered anatomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/ajg.0000000000001102DOI Listing
April 2021

Digital Cholangioscopic Interpretation: When North Meets the South.

Dig Dis Sci 2021 Mar 30. Epub 2021 Mar 30.

Instituto Ecuatoriano De Enfermedades Digestivas (IECED)-University Hospital Omni, Espiritu Santo University, Guayaquil, Ecuador.

Background: Digital single-operator cholangioscopy (DSOC) (SpyGlass DS™, Boston Scientific, MA, USA) allows for high-definition imaging of the biliary tree. The superior visualization has led to the development of two different sets of criteria to evaluate and classify indeterminate biliary strictures: the Monaco criteria and the criteria in Carlos Robles-Medranda's publication (CRM). Our objective was to assess the interrater agreement (IA) of DSOC interpretation for indeterminate biliary strictures using the two newly published criteria.

Methods: Forty de-identified DSOC video recordings were sent to 15 interventional endoscopists with experience in cholangioscopy. They were asked to score the videos based on the presence of Monaco Classification criteria: stricture, lesion, mucosal changes, papillary projections, ulceration, white linear bands or rings, and vessels. Next, they scored the videos using CRM criteria: villous pattern, polypoid pattern, inflammatory pattern, flat pattern, ulcerate pattern and honeycomb pattern. The endoscopists then diagnosed the recordings as neoplastic or non-neoplastic based on the criteria. Intraclass correlation (ICC) analysis was done to evaluate interrater agreement for both criteria set and final diagnosis.

Results: Recordings of 26 malignant lesions and 14 benign lesions were scored. The IA using both the Monaco criteria and CRM criteria ranged from poor to excellent (range 0.1-0.76) and (range 0.1-0.62), respectively. Within the Monaco criteria, IA was excellent for lesion (0.75) and fingerlike papillary projections (0.74); good for tortuous vessels (0.7), mucosal features (0.62), uniform papillary projections (0.53), and ulceration (0.58); and fair for white linear bands (0.4). Within the CRM criteria, the IA was good for villous pattern (0.62), flat pattern (0.62), and honeycomb pattern; fair for ulcerated pattern (0.56), polypoid pattern (0.52) and inflammatory pattern (0.54). The diagnostic IA using Monaco criteria was good (0.65), while the diagnostic IA using CRM was fair (0.58). The overall diagnostic accuracy using the Monaco classification was 61% and CRM criteria were 57%.

Conclusion: The IOA and accuracy rate of DSOC using visual criteria from both Monaco Criteria and CRM are similar. However, some criteria from both sets suffer from poor IA, thus affecting the overall diagnostic accuracy. More formal training and refinements in visual criteria with additional validation are needed to improve diagnostic accuracy.

Trial Registration: ClinicalTrials.gov Identifier: NCT02166099.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-06961-zDOI Listing
March 2021

Photodynamic Therapy (PDT), Radiofrequency Ablation (RFA) With Biliary Stents in Palliative Treatment of Unresectable Extrahepatic Cholangiocarcinoma: A Systematic Review and Meta-analysis.

J Clin Gastroenterol 2021 Mar 12. Epub 2021 Mar 12.

*Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT †Department of Gastroenterology and Hepatology, CHI-Creighton University Medical Center, Omaha, NE ‡Section of Gastroenterology, Rush University Medical Center, Chicago, IL §Department of Internal Medicine, Mayo Clinic, Rochester, MN ∥Department of Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA ¶Gastrointestinal Endoscopy Unit, Hospital Das Clinicas, University of Sao Paulo, Sao Paulo, Brazil.

Background And Aim: Extrahepatic unresectable cholangiocarcinoma carries a dismal prognosis. In addition to biliary drainage by stent placement; photodynamic therapy (PDT) and radiofrequency ablation (RFA) have been tried to prolong survival. In this meta-analysis, we appraise the current known data on the use of PDT, RFA in the palliative treatment of extrahepatic unresectable cholangiocarcinoma.

Methods: We searched multiple databases from inception through July 2020 to identify studies that reported on PDT and RFA. Pooled rates of survival, stent patency, 30-, 90-day mortality, and adverse events were calculated. Study heterogeneity was assessed using I% and 95% prediction interval.

Results: A total of 55 studies (2146 patients) were included. A total of 1149 patients underwent treatment with PDT (33 studies), 545 with RFA (22 studies), and 452 patients with stent-only strategy. The pooled survival rate with PDT, RFA, and stent-only groups was 11.9 [95% confidence interval (CI): 10.7-13.1] months, 8.1 (95% CI: 6.4-9.9) months, and 6.7 (95% CI: 4.9-8.4) months, respectively. The pooled time of stent patency with PDT, RFA, and stent-only groups was 6.1 (95% CI: 4.2-8) months, 5.5 (95% CI: 4.2-6.7) months, and 4.7 (95% CI: 2.6-6.7) months, respectively. The pooled rate of 30-day mortality with PDT was 3.3% (95% CI: 1.6%-6.7%), with RFA was 7% (95% CI: 4.1%-11.7%) and with stent-only was 4.9% (95% CI: 1.7%-13.1%). The pooled rate of 90-day mortality with PDT was 10.4% (95% CI: 5.4%-19.2%) and with RFA was 16.3% (95% CI: 8.7%-28.6%).

Conclusion: PDT seemed to demonstrate better overall survival and 30-day mortality rates than RFA and/or stent-only palliation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MCG.0000000000001524DOI Listing
March 2021

The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding.

Gastrointest Endosc Clin N Am 2021 Apr;31(2):317-330

University of Utah School of Medicine, 30 North 1900 East 4R118, Salt Lake City, UT 84132, USA.

The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.giec.2021.01.001DOI Listing
April 2021

Intracystic Glucose Levels in Differentiating Mucinous From Nonmucinous Pancreatic Cysts: A Systematic Review and Meta-analysis.

J Clin Gastroenterol 2021 Mar 18. Epub 2021 Mar 18.

Department of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT Brigham and Women's Hospital, Harvard Medical School, Boston, MA Department of Internal Medicine, Mayo Clinic, Rochester, MN Department of Internal Medicine, Roanoke Carilion Medical Center, Roanoke, VA Department of Gastroenterology, CHI Creighton University Medical Center, Omaha, NE Gastroenterology Unit, University of Foggia, Foggia Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palemo, Italy Department of Gastroenterology, Aster MIMS, Calicut, Kerala, India.

Background: Mucinous pancreatic cysts are well reported to transform into pancreatic adenocarcinoma, whereas nonmucinous cysts are mostly benign with low risk for malignant transformation. Nonsurgical methods of differentiating mucinous and nonmucinous pancreatic cysts are challenging and entail a multi investigational approach. Low intracystic glucose levels have been evaluated in multiple studies for its accuracy in differentiating mucinous from nonmucinous cysts of the pancreas.

Methods: Multiple databases were searched and studies that reported on the utility of intracystic glucose levels in diagnosing mucinous pancreatic cysts were analyzed. Meta-analysis was conducted using the random-effects model, heterogeneity was assessed by I2%, and pooled diagnostic test accuracy values were calculated.

Results: Seven studies were included in the analysis from an initial total of 375 citations. The pooled sensitivity of low glucose in differentiating mucinous pancreatic cyst was 90.5% [95% confidence interval (CI): 88.1-92.5; I2=0%] and the pooled specificity was 88% (95% CI: 80.8-92.7; I2=79%). The sensitivity at a glucose cut-off of 50 was 90.1% (95% CI: 87.2-92.5; I2=0%) and the specificity was 85.3% (95% CI: 76.8-91.1; I2=76%). The sensitivity of glucose levels in pancreatic cyst fluid taken by endoscopic ultrasound guided fine-needle aspiration was 90.8% (95% CI: 87.9-93.1; I2=0%) and the specificity was 90.5% (95% CI: 81.7-95.3; I2=83%). The sensitivity of point-of-care glucometers was 89.5% (95% CI: 87.9-93.1; I2=0%) and specificity was 83.9% (95% CI: 68.5-92.6; I2=43%).

Conclusions: Low glucose level at a cut-off of 50 mg/dL on fluid samples collected by endoscopic ultrasound guided fine-needle aspiration and analyzed by point-of-care glucometer achieves excellent diagnostic accuracy in differentiating mucinous pancreatic cysts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MCG.0000000000001507DOI Listing
March 2021

Real-World Experience of Intragastric Balloons for Obesity: Insights from the FDA Manufacturer and User Facility Device Experience (MAUDE) Database.

Obes Surg 2021 07 9;31(7):3360-3364. Epub 2021 Mar 9.

Division of Gastroenterology and Hepatology, Huntsman Cancer Center, University of Utah School of Medicine, 30N 1900E 4R118, Salt Lake City, UT, USA.

Intragastric balloons have been used to bridge the obesity treatment gap. We aim to investigate the number and type of complications associated with intragastric balloons using public-access governmental databanks. We analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from Jan 2017 through Nov 2020. During the study period, approximately 773 cases with 830 device issues and 1134 patient complications were identified. Most balloon complications were due to leaks (33.4%). The most reported adverse events were vomiting (26.6%), abdominal pain (25.3%), and nausea (15.8%). Findings from the MAUDE database highlight patient and device adverse outcomes that should be addressed to improve clinical success.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11695-021-05324-xDOI Listing
July 2021

Efficacy of EUS-guided needle-based confocal laser endomicroscopy in the diagnosis of pancreatic lesions: A systematic review and meta-analysis.

Endosc Ultrasound 2021 Mar 2. Epub 2021 Mar 2.

Huntsman Cancer Center, University of Utah School of Medicine, Salt Lake City, UT, USA.

Background And Objectives: Needle-based confocal laser endomicroscopy (nCLE) is a procedure in which an AQ-Flex nCLE mini-probe is passed through an EUS-FNA needle into a pancreatic lesion to enable subsurface in vivo tissue analysis. In this study, we conducted a systematic review and meta-analysis of nCLE for the diagnosis of pancreatic lesions.

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 March 2020). The primary outcomes assessed the pooled rate of diagnostic accuracy for nCLE and the secondary outcomes assessed the pooled rate of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and adverse events (AE) of nCLE to diagnose premalignant/malignant pancreatic lesions.

Results: Eleven studies on 443 patients were included in our analysis. The pooled rate of diagnostic accuracy of EUS nCLE was 83% (95 confidence interval [CI] = 79-87; I 2 = 0). The pooled rate of sensitivity, specificity, PPV and NPV of EUS nCLE was 85.29% (95% CI = 76.9-93.68; I 2 = 85%), 90.49% (95% CI = 82.24-98.74; I 2 = 64%), 94.15% (95% CI = 88.55-99.76; I 2 = 68%), and 73.44% (95% CI = 60.16-86.72; I 2 = 93%), respectively. The total AE rate was 5.41% (±5.92) with postprocedure pancreatitis being the most common AE at 2.28% (±3.73).

Conclusion: In summary, this study highlights the rate of diagnostic accuracy, sensitivity, specificity, and PPV for distinguishing premalignant/malignant lesions. Pancreatic lesions need to be further defined with more validation studies to characterize CLE diagnosis criteria and to evaluate its use as an adjunct to EUS-FNA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/EUS-D-20-00122DOI Listing
March 2021

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

Endosc Int Open 2021 Mar 22;9(3):E496-E504. Epub 2021 Feb 22.

Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States.

 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.  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 % and 95 % confidence interval.  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  = 42) and 93.3 % (CI 84.4-97.3, I  = 59) while for ES it was 96.9 % (CI 90.9-99, I  = 64) and 85.6 % (CI 73-92.9, I  = 85), respectively. Pooled rate of re-intervention was significantly lower with EUS-GE i. e. 4 % (CI 1.8-8.7, I  = 35) compared to ES, where it was 23.6 % (CI 17.5-31, I  = 35), p = 0.001 Pooled rates of overall and major AEs were comparable between the two techniques.  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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1341-0788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899789PMC
March 2021

International, multicenter retrospective trial comparing the efficacy and safety of bi-flanged versus lumen-apposing metal stents for endoscopic drainage of walled-off pancreatic necrosis.

Ann Gastroenterol 2021 4;34(2):273-281. Epub 2021 Jan 4.

University of Utah, Salt Lake City, UT, USA (Douglas G. Adler).

Background: To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON).

Methods: Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated.

Results: 387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P<0.001). Technical success for stent placement was similar in BFMS and LAMS groups (203 [99%] vs. 180 [99%], P=0.90). Procedure-related AEs were similar in the BFMS and LAMS groups (19 [9.3%] vs. 20 [10.9%], P=0.61). Stent dysfunction with occluding debris was higher in the BFMS group compared to LAMS group (21 [10.2 %] vs. 11 [5.9%], P=0.04). The migration rate was higher in the BFMS group than in the LAMS group (15 [7.3%] vs. 3 [1.6%]; P<0.001). DEN was required in 23 [11.2%] patients in the BFMS group after lack of WON resolution by conservative means.

Conclusion: BFMS with a "step-up approach" and LAMS with scheduled DEN are both safe and effective for EUS-guided drainage/debridement of WON.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20524/aog.2021.0570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903561PMC
January 2021

Acute biliary pancreatitis has better outcomes but increased resource utilization compared to acute alcohol-induced pancreatitis: insights from a nationwide study.

Ann Gastroenterol 2021 7;34(2):253-261. Epub 2020 Dec 7.

Department of Gastroenterology, University of Utah, Salt Lake City, UT (Douglas G. Adler), USA.

Background: The differences in outcomes between acute biliary pancreatitis (ABP) and acute alcohol-induced pancreatitis (AAP) have not been well studied. We sought to examine the differences between ABP and AAP as regards to in-hospital outcomes and resource utilization, using a large nationwide database.

Methods: We queried the National Inpatient Sample databases 2016 and 2017 using the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) coding system to identify the patients with a primary diagnosis of AAP and ABP. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), hospitalization charge/cost, shock, acute kidney injury (AKI), intensive care unit (ICU) admission, and home discharge. Analysis was performed with STATA software.

Results: There was no significant difference in mortality between patients with AAP and ABP (0.42% vs. 0.82%, adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.69-1.31; P=0.79). Patients with ABP had a significantly longer LOS (+0.48 days, P<0.001). Patients with ABP had significantly higher adjusted mean hospitalization charges ($+19,958, P<0.001) and costs ($+4,848, P<0.001). Patients with ABP had a significantly lower likelihood of shock (aOR 0.75, 95%CI 0.59-0.95; P=0.02), AKI (aOR 0.76, 95%CI 0.71-0.82; P<0.001) or ICU admission (aOR 0.74, 95%CI 0.62-0.88; P=0.001). They were more likely to be discharged home (aOR 1.26, 95%CI 1.18-1.34; P<0.001).

Conclusion: Although there was no difference in all-cause mortality, patients with ABP had better hospitalization outcomes but greater resource utilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20524/aog.2020.0559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903563PMC
December 2020

Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

Ann Gastroenterol 2021 7;34(2):155-163. Epub 2020 Dec 7.

Division of Gastroenterology, University of Utah, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler).

Background: Heller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM.

Methods: We searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM.

Results: We included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM.

Conclusions: POEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20524/aog.2020.0563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903572PMC
December 2020

The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

J Clin Gastroenterol 2021 May-Jun 01;55(5):e37-e45

Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT.

Goals/background: Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding.

Study: We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray.

Results: A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy.

Conclusions: Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MCG.0000000000001379DOI Listing
July 2021
-->