Dhruvika Mukhija

Statin use and the risk of clostridium difficile infection: A systematic review with meta-analysis

Purpose Statins have pleiotropic effects beyond cholesterol lowering by immune modulation. The association of statins with primary Clostridium difficile infection (CDI) is unclear as studies have reported conflicting findings. We performed a systematic review and meta-analysis to evaluate the association between statin use and CDI. Patients and methods We searched MEDLINE, Embase, and Web of Science from January 1978 to December 2016 for studies assessing the association between statin use and CDI. The Newcastle–Ottawa Scale was used to assess the methodologic quality of included studies. Weighted summary estimates were calculated using generalized inverse variance with random-effects model. Results Eight studies (6 case–control and 2 cohort) were included in the meta-analysis, which comprised 156,722 patients exposed to statins and 356,185 controls, with 34,849 total cases of CDI available in 7 studies. The rate of CDI in patients with statin use was 4.3%, compared with 7.8% in patients without statin use. An overall meta-analysis of 8 studies using the random-effects model demonstrated that statins may be associated with a decreased risk of CDI (maximally adjusted odds ratio [OR], 0.80; 95% CI, 0.66–0.97; P=0.02). There was significant heterogeneity among the studies, with an I2 of 79%. No publication bias was seen. Meta-analysis of studies that adjusted for confounders revealed no protective effect of statins (adjusted OR, 0.84; 95% CI, 0.70–1.01; P=0.06, I2=75%). However, a meta-analysis of only full-text studies using the random-effects model demonstrated a decreased risk of CDI with the use of statins (OR 0.77; 95% CI, 0.61–0.99; P=0.04, I2=85%). Conclusion Meta-analyses of existing studies suggest that patients prescribed a statin may be at decreased risk for CDI. The results must be interpreted with caution given the significant heterogeneity and lack of benefit on analysis of studies that adjusted for confounders.

Successful Curative Resection of Early Gastric Cancer by Endoscopic Submucosal Dissection in a High-Risk Cirrhotic Patient

Endoscopic submucosal dissection (ESD) technique was developed in the 1990s for the treatment of early gastric cancer (EGC) [1]. ESD enables en bloc resection, provides adequate histopathological staging and long-term cure rates similar to surgery with lower morbidity, and is considered superior to the piecemeal endoscopic mucosal resection (EMR) technique. However, due to the lower prevalence of gastric cancer and the absence of a universal endoscopic screening program in the USA, cases of EGC are extremely rare [2]. We report a case of EGC in a high-risk surgical patient successfully treated with ESD.

Technique for Retrieving Basket and Lithotripter During Endoscopic Retrograde Cholangiopancreatography

27-year-old woman with a prior cholecystectomy Aunderwent endoscopic retrograde cholangio pancreatography (ERCP) for abdominal pain and choledocholithiasis. After biliary sphincterotomy, a flower basket was used to grasp and retrieve a 15-mm mid– common bile duct (CBD) stone. However, the flower basket became impacted in the CBD (Figure A). Then, the distal CBD was dilated using a 15-mm CRE balloon dilator (Boston Scientific, Natick, MA). Despite this, the basket could not be pulled out. The outer plastic sheath of the basket was removed and a Soehendra mechanical lithotripter then was inserted alongside the basket wires into the CBD and mechanical lithotripsy (Cook Medical, Winston-Salem, NC) of the stone was attempted. The lithotripter also became impacted in the CBD over the basket (Figure B) and could not be pulled out. The presence of the impacted basket, lithotripter, and wires in the CBD precluded placement of a stent, but there was good bile drainage seen. Because of the prolonged efforts and complexity, it was elected to terminate the procedure. The basket and lithotripter wires were cut and secured at the patient’s mouth with an adhesive tape. The patient was placed on a liquid diet along with broad-spectrum antibiotics for prophylaxis against cholangitis. ERCP was repeated after 3 days and attempts to drag the impacted devices and stone with an extraction balloon were unsuccessful. Electrohydraulic lithotripsy (EHL) then was performed using Spyglass (Boston Scientific) and the stone was fragmented. The impacted basket and lithotripter could be pulled out of the bile duct by using a rat-tooth forceps, passed under endoscopic and fluoroscopic guidance (Figure C). An extraction balloon was swept to clear the residual stone fragments. A 10F 10-cm plastic stent was inserted temporarily for 4 weeks to ensure biliary drainage and the patient did well.