Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies

Endoscopic Ultrasound-Guided Fine Needle Aspiration and Endoscopic Retrograde Cholangiopancreatography-Based Tissue Sampling in Suspected Malignant Biliary Strictures: A Meta-Analysis of Same-Session Procedures

Background/Aims: The diagnosis of biliary strictures can be challenging. There are no systematic reviews studying same-session endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis of biliary strictures. Methods: A systematic review was conducted on studies analyzing same-session EUS and ERCP for tissue diagnosis of suspected malignant biliary strictures. The primary outcome was the accuracy of each method individually compared to the two methods combined. The secondary outcome was the accuracy of each method in pancreatic and biliary etiologies. In the meta-analysis, we used Forest plots, summary receiver operating characteristic curves, and estimates of the area under the curve for intention-to-treat analysis. Results: Of the 12,132 articles identified, six were included, resulting in a total of 497 patients analyzed. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and accuracy of the association between the two methods were: 86%, 98%, 12.50, 0.17, and 96.5%, respectively. For the individual analysis, the sensitivity, specificity and accuracy of EUS-FNA were 76%, 100%, and 94.5%, respectively; for ERCP-based tissue sampling, the sensitivity, specificity, and accuracy were 58%, 98%, and 78.1%, respectively. For pancreatic lesions, EUS-FNA was superior to ERCP-based tissue sampling. However, for biliary lesions, both methods had similar sensitivities. Conclusions: Same-session EUS-FNA and ERCP-based tissue sampling is superior to either method alone in the diagnosis of suspected malignant biliary strictures. Considering these results, combination sampling should be performed when possible

A comparison of the efficiency of 22G versus 25G needles in EUS-FNA for solid pancreatic mass assessment: A systematic review and meta-analysis

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions

Insufflation of Carbon Dioxide versus Air During Colonoscopy Among Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims: Carbon dioxide is increasingly used in insufflation during colonoscopy in adult patients; however, air insufflation remains the primary practice among pediatric gastroenterologists. This systematic review and meta-analysis aims to evaluate insufflation using CO2 versus air in colonoscopies in pediatric patients. Methods: Individualized search strategies were performed using MEDLINE, Cochrane Library, EMBASE, and LILACS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane working methodology. Randomized control trials (RCTs) were selected for the present meta-analysis. Pooled proportions were calculated for outcomes including procedure time and abdominal pain immediately and 24 hours post-procedure. Results: The initial search yielded 644 records, of which five RCTs with a total of 358 patients (CO2: n=178 versus air: n=180) were included in the final analysis. The procedure time was not different between the CO2 and air insufflation groups (mean difference, 10.84; 95% confidence interval [CI], -2.55 to 24.22; p=0.11). Abdominal pain immediately post-procedure was significantly lower in the CO2 group (risk difference [RD], -0.15; 95% CI; -0.26 to -0.03; p=0.01) while abdominal pain at 24 hours post-procedure was similar (RD, -0.05; 95% CI; -0.11 to 0.01; p=0.11). Conclusions: Based on this systematic review and meta-analysis of RCT data, CO2 insufflation reduced abdominal pain immediately following the procedure, while pain was similar at 24 hours post-procedure. These results suggest that CO2 is a preferred insufflation technique when performing colonoscopy in pediatric patients

Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07‒0.51; p = 0.009 I² = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06‒0.33; p < 0.0001; I² = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05‒0.16; p < 0.0001; I² = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 ‒ -2,43; p < 0.00001; I² = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 ‒ -0.11; p < 0.00001; I² = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01‒0.15; p = 0.02; I² = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases

Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic. Methods A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Results Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I2=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I2=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I2=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I2=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events. Conclusions EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements

Approach to Endoscopic Procedures: A Routine Protocol from a Quaternary University Referral Center Exclusively for Coronavirus Disease 2019 Patients

OBJECTIVES: The present coronavirus disease (COVID-19) pandemic has ushered in an unprecedented era of quality control that has necessitated advanced safety precautions and the need to ensure the adequate protection of healthcare professionals (HCPs). Endoscopy units, endoscopists, and other HCP may be at a significant risk for transmission of the virus. Given the immense burden on the healthcare system and surge in the number of patients with COVID-19, well-designed protocols and recommendations are needed. We aimed to systematically characterize our approach to endoscopic procedures in a quaternary university hospital setting and provide summary protocol recommendations. METHOD: This descriptive study details a COVID-19-specific protocol designed to minimize infection risks to patients and healthcare workers in the endoscopy unit. RESULTS: Our institution, located in Sa˜o Paulo, Brazil, includes a 900-bed hospital, with a 200-bed-specific intensive care unit exclusively designed for patients with moderate and severe COVID-19. We highlighted recommendations for infection prevention and control during endoscopic procedures, including appropriate triage and screening, outpatient management and procedural recommendations, role and usage of personal protective equipment (PPE), and role and procedural logistics involving COVID-19-positive patients. We also detailed hospital protocols for reprocessing endoscopes and cleaning rooms and also provided recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission. CONCLUSION: This COVID-19-specific administrative and clinical protocol can be replicated or adapted in multiple institutions and endoscopy units worldwide. Furthermore, the recommendations and summary protocol may improve patient and HCP safety in these trying times

Laparoscopic cardiomyotomy with fundoplication compared top endoscopic peroral myotomy in patients with esophageal achalasia

Introdução: Acalásia é um distúrbio motor esofagiano benigno, que se caracteriza pelo relaxamento incompleto do esfíncter inferior do esôfago em resposta à deglutição associado a aperistalse do corpo esofágico podendo ser classificada como primária ou idiopática e a secundária quando resultante de outra doença sistêmica. Disfagia progressiva e perda de peso são sintomas frequentes. O diagnóstico habitualmente raio-X contrastado do esôfago-estômago-duodeno, a endoscopia digestiva alta e a manometria esofágica convencional ou de alta resolução. O tratamento da acalásia, não é curativo, baseia-se na redução da pressão do esfíncter inferior do esôfago, que pode ser alcançada por drogas, injeção de toxina botulínica, dilatação pneumática, miotomia endoscópica ou miotomia cirúrgica. Método: Comparar em ensaio clínico randomizado a eficácia entre a abordagem cirúrgica por meio da cardiomiotomia com fundoplicatura parcial videolaparoscópica e a miotomia endoscópica peroral no tratamento de pacientes portadores de acalásia sem tratamentos prévios, independente de sua etiologia, no período de 1 ano. Os objetivos primários foram a melhora dos sintomas e a ocorrência de esofagite de refluxo, enquanto que os objetivos secundários foram avaliar a altura da coluna de bário com 1 e 5 minutos, pressão do esfíncter inferior do esôfago, eventos adversos, tempo de internação, tempo de anestesia, tempo de procedimento e qualidade de vida. Foram avaliados 40 pacientes adultos, portadores de acalásia do esôfago, não submetidos a nenhuma modalidade prévia de tratamento da disfagia, oriundos de um centro único. Resultado: Um total de 40 pacientes foram aleatoriamente designados para miotomia com fundoplicatura parcial videolaparoscópica ou para a miotomia endoscópica. O período de acompanhamento foi de um ano. Não houve diferença estatística entre os dois grupos em relação ao objetivo primário; melhora dos sintomas no seguimento de 1 mês, 6 meses e 1 ano (p=0,192, p=0,242 e p=0,242), entretanto, em relação a taxa de esofagite, os pacientes que realizaram o POEM tiveram taxas mais elevadas de esofagite em comparação com o grupo que realizou CM-FP-VLP, com significância estatística, em 1 mês, 6 meses e 1 ano após o procedimento (p = 0,014; p < 0,001; p = 0,002). Após 1 mês, 6 meses e 1 ano as taxas de esofagite foram 0,0%, 5.6% e 11.1% no grupo CM-FP-VLP e 29,4%, 62,5% e 64,6% no grupo do POEM, respectivamente. Na análise por intenção de tratamento, não houve diferença estatística entre os dois grupos com relação aos valores da altura da coluna de bário com 1 e 5 minutos no seguimento de 6 meses e 1 ano (p= 0,429 e p= 0,773), também não houve diferença estatística entre os dois grupos nos períodos de seguimento de 6 meses e 1 ano (p=0,848) em relação a diminuição nos valores da PEM. Também não houve diferença estatística com relação aos eventos adversos entre os procedimentos (p= 0,605), não houve diferença estatística entre os dois grupos com relação ao tempo de internação (CM-FP-VLP: 3,95 ± 3,36 dias; POEM: 3,40 ± 0,75 dias; p = 0,483), entretanto, no grupo do POEM observou-se menor tempo de anestesia (185,00 ± 56,89 min) e menor tempo de procedimento (95,70 ± 30,47) em comparação com o grupo CM-FP-VLP (296,75 ± 56,13 min e 218,75 ± 50,88 min) (p<0,001). Em relação a avaliação da qualidade de vida SF-36, no grupo POEM, houve melhora em todos os domínios no seguimento pós-procedimento em relação ao pré-procedimento, enquanto que no grupo CM-FP-VLP, houve melhora em 3 domínios. Conclusão: As técnicas de miotomia cirúrgica e endoscópica, são procedimentos igualmente eficazes no controle dos sintomas (disfagia, dor, regurgitação e perda de peso) e em relação a ocorrência de eventos adversos, tempo de internação e qualidade de vida. Entretanto há uma maior taxa de refluxo gastroesofágico, menor tempo de anestesia e menor tempo de procedimento no grupo da miotomia endoscópicaIntroduction: Achalasia is a benign esophageal motor disorder, which is characterized by incomplete relaxation of the lower esophageal sphincter in response to swallowing associated with aperistalsis of the esophageal body and can be classified as primary or idiopathic and secondary when resulting from another systemic disease. Progressive dysphagia and weight loss are frequent symptoms. Diagnosis usually contrasted X-ray of the esophagus- stomach-duodenum, upper digestive endoscopy, and conventional or high- resolution esophageal manometry. The treatment of achalasia is not curative, it is based on reducing the pressure of the lower esophageal sphincter, which can be achieved by drugs, botulinum toxin injection, pneumatic dilation, endoscopic myotomy, or surgical myotomy. Methods: To compare, in a randomized clinical trial, the efficacy between the surgical approach using laparoscopic cardiomyotomy with partial fundoplication (LCPF) and peroral endoscopic myotomy in the treatment of patients with achalasia without previous treatments, regardless of their etiology, in the period of 1 year. The primary objectives were the improvement of symptoms and the occurrence of reflux esophagitis, while the secondary objectives were to assess the height of the barium column at 1 and 5 minutes, pressure of the lower esophageal sphincter, adverse events, length of hospital stay, time anesthesia, procedure time and quality of life. Forty adult patients with esophageal achalasia, who had not undergone any previous treatment for dysphagia, from a single center, were evaluated. Results: A total of 40 patients were randomly assigned to laparoscopic cardiomyotomy with partial fundoplication or to endoscopic myotomy. The follow-up period was one year. There was no statistical difference between the two groups in relation to the primary objective; improvement of symptoms at 1 month, 6 months and 1 year (p = 0.192, p = 0.242 and p = 0.242), however, in relation to the rate of esophagitis, patients who underwent POEM had higher rates of esophagitis compared with the group that performed LCPF, with statistical significance, at 1 month, 6 months and 1 year after the procedure (p = 0.014; p <0.001; p = 0.002). After 1 month, 6 months and 1 year, esophagitis rates were 0.0%, 5.6% and 11.1% in the LCPF group and 29.4%, 62.5% and 64.6% in the POEM group, respectively. In the intention-to-treat analysis, there was no statistical difference between the two groups regarding the values of barium column height with 1 and 5 minutes in the 6-month and 1-year follow-up (p = 0.429 and p = 0.773), decrease in the PEM values (p = 0.848), adverse events (p = 0.605) and length of stay (LCPF: 3.95 ± 3.36 days; POEM: 3 , 40 ± 0.75 days; p = 0.483). However, in the POEM group, shorter anesthesia time (185.00 + 56.89 min) and shorter procedure time (95.70 ± 30.47) were observed compared to the LCPF group (296.75 ± 56.13 min and 218.75 ± 50.88 min) (p <0.001). Regarding the evaluation of the SF-36 quality of life, in the POEM group, there was an improvement in all domains in the post- procedure follow-up in relation to the pre-procedure, whereas in the LCPF group, there was an improvement in 3 domains. Conclusion: After one year of follow up, myotomy group, as compared to LCPF, was not associated with superior rates of therapeutic success, control of symptoms (dysphagia, pain, regurgitation and weight loss), occurrence of adverse events, length of hospital stay and quality of life. However, there is a higher rate of gastroesophageal reflux, shorter anesthesia time and shorter procedure time in the endoscopic myotomy grou

Endoscopic pneumatic dilatation and peroral endoscopic myotomy in dilated megaesophagus

Achalasia is a primary esophageal disorderth variable causes, with an incidence between 0.03 to 1/100,000 people, and prevalence of approximately 10/100,000, with no difference between gender. It is more frequent in South and Central America, where Chagas disease is endemic. There are several methods to treat achalasia including endoscopic and surgical procedures, however, all of these methods are palliative. This article discusses 2 different endoscopic methods to treat advanced megaesophagus in Chagas disease, pneumatic balloon dilatation (PBD), and peroral endoscopic myotomy (POEM). Although varying between studies, PBD has an average symptom relief in 93% of patients in 6 months and 44% in 6 years. Some risk factors for failure of PBD are: younger age, male gender, a wider esophagus, poor emptying on post-treatment barium esophagogram and Eckardt scale &lt; 3 before the treatment. Despite relatively short-term follow-up of an average of 3 years, POEM has excellent results. The clinical success achieved in 98 % with the Eckardt score decreased from 6.9 preoperatively to 0.77. Regarding sigmoid-shaped esophagus, only a few papers have been published on POEM. The largest population was 32 patients with a follow-up of 2 years. There was an efficacy of 96%, with the Eckardt scale decreasing from 7.8 to 1.4. In conclusion, PBD, is still widely used mainly due to its availability, especially in patients with a higher surgical risk and in patients who already had a Heller myotomy who persist or develop dysphagia. POEM has already demonstrated excellent results, but it requires advanced technical skills and Long-term results and randomized clinical trials are needed to validate the use of POEM in routine clinical practice