Abhishek Choudhary

Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting. OBJECTIVE We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy. DESIGN Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models. SETTING Literature search. PATIENTS Per RCTs. MAIN OUTCOME MEASUREMENTS Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects. RESULTS Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P < .01) and willingness to repeat the same preparation (OR 1.76; 95% CI, 1.06-2.91; P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P < .01) compared with full-dose PEG. LIMITATIONS Limited number of studies. CONCLUSIONS The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

BACKGROUND Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. OBJECTIVE We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. DESIGN MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency. SETTING Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. PATIENTS Adult patients undergoing ERCP. INTERVENTIONS Pancreatic stent placement for the prevention of post-ERCP pancreatitis. MAIN OUTCOME MEASUREMENTS Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. RESULTS Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies. LIMITATIONS Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. CONCLUSIONS Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis

BackgroundThe role of prophylactic antibiotics in laparoscopic cholecystectomy in low-risk patients is controversial. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low-risk patients (those without cholelithiasis or cholangitis) undergoing laparoscopic cholecystectomy.MethodsMultiple databases and abstracts were searched. Randomized controlled trials (RCTs) comparing prophylactic antibiotics to placebo or no antibiotics in low-risk laparoscopic cholecystectomy were included. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of overall infections, superficial wound infections, major infections, distant infections, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio or weighted mean difference. Both random and fixed effects models were used. Publication bias was assessed by funnel plot. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.ResultsNine RCTs (N = 1,437) met the inclusion criteria. No statistically significant reduction was noted for those receiving prophylactic antibiotics and those who did not for overall infectious complications (p = 0.20), superficial wound infections (p = 0.36), major infections (p = 0.97), distant infections (p = 0.28), or length of hospital stay (p = 0.77). No statistically significant publication bias or heterogeneity were noted.ConclusionsProphylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy.

Effect of Helicobacter pylori treatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials.

Abstract Objective. Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD. Material and methods. Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. Results. Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56–1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72–1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35–0.87, p = 0.01). Funnel plot revealed no publication bias. Conclusions. Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis

BACKGROUND: Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (≤4 h) after PEG placement.METHODS: Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (≤4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death ≤72 h, and significant increases in postprocedural gastric residual volume during day 1.RESULTS: Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (≤4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47–1.58, P = 0.63) or death in ≤72 h (OR 0.56, 95% CI 0.18–1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02–3.19, P = 0.04).CONCLUSIONS: Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.

Prophylactic antibiotics in necrotizing pancreatitis: a meta-analysis.

Purpose: Prophylactic antibiotics have been used in acute necrotizing pancreatitis with mixed results. This meta-analysis analyzes the effects of prophylactic antibiotics in necrotizing pancreatitis. Methods: Multiple databases and abstracts were searched for randomized trials comparing treatment with prophylactic antibiotics to treatment without prophylactic antibiotics in necrotizing pancreatitis. Prophylactic antibiotics’ effects were analyzed by calculating pooled estimates of mortality, infected pancreatic necrosis, length of hospital stay, nonpancreatic infections, and surgical intervention. Results: Seven studies (n = 429) met the inclusion criteria. Prophylactic antibiotics for acute necrotizing pancreatitis significantly decreased the length of hospital stay (P = 0.04) and the rate of nonpancreatic infections (P < 0.01). No significant differences were noted for mortality (P = 0.22), infected necrosis (P = 0.18), and surgical intervention (P = 0.40). Conclusions: Prophylactic antibiotics in necrotizing pancreatitis reduced the length of hospital stay and rate of nonpancreatic infections but did not decrease mortality, infected necrosis, or surgical intervention.

Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials.

Background/Aim: Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. Methods: Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). Results: Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01). Conclusions: Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: A meta-analysis

Abstract Objective. Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. Materials and methods. Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). Results. Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85–8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24–0.74, p < 0.01), and a trend for less units of blood transfused (WMD −0.48; 95% CI −0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. Conclusions. Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.

Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis.

Background Traditionally, tube feedings have been delayed after gastrostomy placement to the next day and up to 24 hours postprocedure. However, results from various randomized clinical trials (RCTs) indicate earlier feeding may be an option. Therefore, we conducted a meta-analysis to analyze the effect of earlier feedings (⩽3 h) after percutaneous endoscopic gastrostomy (PEG) placement. Methods Various medical databases and recent abstracts from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early (⩽3 h) versus delayed or next-day feedings after PEG placement were included. Meta-analysis was performed using pooled estimates of complications, death ⩽72 hours, and significant increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.0 was utilized for statistical analysis. Results Five studies (N=355) met the inclusion criteria. No significant differences were noted between early (⩽3 h) and delayed or next day feedings for patient complications [OR 0.78; 95% confidence interval (CI), 0.39-1.53; P=0.47], death in ⩽72 hours (OR 0.60; 95% CI, 0.18-1.99; P=0.40), and number of significant gastric residual volume during day 1 (OR 1.46; 95% CI, 0.75-2.84; P=0.27). No publication bias and no significant heterogeneity were noted. Conclusions Early tube feeding ⩽3 hours after PEG placement has no significant differences to delayed or next-day feeding in respect to complications, death in ⩽72 hours, or number of significant gastric residual volumes at day 1.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis.

Objectives Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). Methods A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. Results Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34–0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32–0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24–0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. Conclusions Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.