Leonardo Zorron Cheng Tao Pu

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis

AIM To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction. METHODS A systematic review of randomized clinical trials (RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL (EBSCO), MEDLINE, LILACS/CENTRAL (BVS), SCOPUS, CAPES (Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and re-intervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables and mean differences (MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ (2) and the Higgins method (I (2)). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Students t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes. RESULTS Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents (SEMS) and plastic stents (PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct (proximal) and pancreatic tumors (distal). The preferred SEMS diameter used was the 10 mm (30 Fr) and the preferred PS diameter used was 10 Fr. In the meta-analysis, SEMS had lower overall stent dysfunction compared to PS (21.6% vs 46.8%, P < 0.00001) and fewer re-interventions (21.6% vs 56.6%, P < 0.00001), with no difference in complications (13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group (182 d vs 150 d, P < 0.0001), with a higher patency period (250 d vs 124 d, P < 0.0001) and a lower cost per patient (4193.98 vs 4728.65 Euros, P < 0.0985). CONCLUSION SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.

Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials.

BackgroundPeptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy.MethodsStudies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials.ResultsTwenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone.ConclusionsInjection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.

Achalasia: from diagnosis to management

Achalasia is an esophageal motility disorder associated with abnormalities in peristalsis and lower esophageal sphincter (LES) relaxation. The etiology of the disease remains elusive. It is often misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia to solids and liquids but may focus on regurgitation as the primary symptom, leading to the early misdiagnosis. Chest pain, weight loss, and occasional vomiting may be additional symptoms encountered in those with achalasia. The disease may be suspected on the basis of clinical presentation, but diagnosis depends on classic findings using high‐resolution manometry, showing either failed or simultaneous contractions with associated normal or high LES pressures with no or incomplete relaxation with swallows. There are no cures for achalasia, and, in most patients, treatments have to be repeated over time. Definitive treatment options in achalasia include pneumatic dilation, surgical myotomy, and the new technique of per‐oral endoscopic myotomy. Botulinum toxin (Botox) or other medical therapies are often reserved for those who cannot have definitive therapies owing to comorbid conditions.

Malignant Biliary Obstruction: Evidence for Best Practice

What should be done next? Is the stricture benign? Is it resectable? Should I place a stent? Which one? These are some of the questions one ponders when dealing with biliary strictures. In resectable cases, ongoing questions remain as to whether the biliary tree should be drained prior to surgery. In palliative cases, the relief of obstruction remains the main goal. Options for palliative therapy include surgical bypass, percutaneous drainage, and stenting or endoscopic stenting (transpapillary or via an endoscopic ultrasound approach). This review gathers scientific foundations behind these interventions. For operable cases, preoperative biliary drainage should not be performed unless there is evidence of cholangitis, there is delay in surgical intervention, or intense jaundice is present. For inoperable cases, transpapillary stenting after sphincterotomy is preferable over percutaneous drainage. The use of plastic stents (PS) has no benefit over Self-Expandable Metallic Stents (SEMS). In case transpapillary drainage is not possible, Endoscopic Ultrasonography- (EUS-) guided drainage is still an option over percutaneous means. There is no significant difference between the types of SEMS and its indication should be individualized.

Multicenter randomised controlled trial comparing the high definition white light endoscopy and the bright narrow band imaging for colon polyps

AIM To compare high definition white light endoscopy and bright narrow band imaging for colon polyps’ detection rates. METHODS Patients were randomised to high definition white light endoscopy (HD-WLE) or the bright narrow band imaging (bNBI) during withdrawal of the colonoscope. Polyps identified in either mode were characterised using bNBI with dual focus (bNBI-DF) according to the Sano’s classification. The primary outcome was to compare adenoma detection rates (ADRs) between the two arms. The secondary outcome was to assess the negative predictive value (NPV) in differentiating adenomas from hyperplastic polyps for diminutive rectosigmoid lesions. RESULTS A total of 1006 patients were randomised to HD-WLE (n = 511) or bNBI (n = 495). The mean of adenoma per patient was 1.62 and 1.84, respectively. The ADRs in bNBI and HD-WLE group were 37.4% and 39.3%, respectively. When adjusted for withdrawal time (OR = 1.19, 95%CI: 1.15-1.24, P < 0.001), the use of bNBI was associated with a reduced ADR (OR = 0.69, 95%CI: 0.52-0.92). Nine hundred and thirty three polyps (86%) in both arms were predicted with high confidence. The sensitivity (Sn), specificity (Sp), positive predictive value and NPV in differentiating adenomatous from non-adenomatous polyps of all sizes were 95.9%, 87.2%, 94.0% and 91.1% respectively. The NPV in differentiating an adenoma from hyperplastic polyp using bNBI-DF for diminutive rectal polyps was 91.0%. CONCLUSION ADRs did not differ between bNBI and HD-WLE, however HD-WLE had higher ADR after adjustment of withdrawal time. bNBI surpassed the PIVI threshold for diminutive polyps.

Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

Sessile serrated adenoma/polyps: Where are we at in 2016?

It is currently known that colorectal cancers (CRC) arise from 3 different pathways: the adenoma to carcinoma chromosomal instability pathway (50%-70%); the mutator “Lynch syndrome” route (3%-5%); and the serrated pathway (30%-35%). The World Health Organization has classified serrated polyps into three types of lesions: hyperplastic polyps (HP), sessile serrated adenomas/polyps (SSA/P) and traditional serrated adenomas (TSA), the latter two strongly associated with development of CRCs. HPs do not cause cancer and TSAs are rare. SSA/P appear to be the responsible precursor lesion for the development of cancers through the serrated pathway. Both HPs and SSA/Ps appear morphologically similar. SSA/P are difficult to detect. The margins are normally inconspicuous. En bloc resection of these polyps can hence be troublesome. A careful examination of borders, submucosal injection of a dye solution (for larger lesions) and resection of a rim of normal tissue around the lesion may ensure total eradication of these lesions.

Randomised controlled trial comparing modified Sano’s and narrow band imaging international colorectal endoscopic classifications for colorectal lesions

AIM To assess the utility of modified Sano′s (MS) vs the narrow band imaging international colorectal endoscopic (NICE) classification in differentiating colorectal polyps. METHODS Patients undergoing colonoscopy between 2013 and 2015 were enrolled in this trial. Based on the MS or the NICE classifications, patients were randomised for real-time endoscopic diagnosis. This was followed by biopsies, endoscopic or surgical resection. The endoscopic diagnosis was then compared to the final (blinded) histopathology. The primary endpoint was the sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of differentiating neoplastic and non-neoplastic polyps (MS II/IIo / IIIa / IIIb vs I or NICE 1 vs 2/3). The secondary endpoints were “endoscopic resectability” (MS II/IIo/IIIa vs I/IIIb or NICE 2 vs 1/3), NPV for diminutive distal adenomas and prediction of post-polypectomy surveillance intervals. RESULTS A total of 348 patients were evaluated. The Sn, Sp, PPV and NPV in differentiating neoplastic polyps from non-neoplastic polyps were, 98.9%, 85.7%, 98.2% and 90.9% for MS; and 99.1%, 57.7%, 95.4% and 88.2% for NICE, respectively. The area under the receiver operating characteristic curve (AUC) for MS was 0.92 (95%CI: 0.86-0.98); and AUC for NICE was 0.78 (95%CI: 0.69, 0.88). The Sn, Sp, PPV and NPV in predicting “endoscopic resectability” were 98.9%, 86.1%, 97.8% and 92.5% for MS; and 98.6%, 66.7%, 94.7% and 88.9% for NICE, respectively. The AUC for MS was 0.92 (95%CI: 0.87-0.98); and the AUC for NICE was 0.83 (95%CI: 0.75-0.90). The AUC values were statistically different for both comparisons (P = 0.0165 and P = 0.0420, respectively). The accuracy for diagnosis of sessile serrated adenoma/polyp (SSA/P) with high confidence utilizing MS classification was 93.2%. The differentiation of SSA/P from other lesions achieved Sp, Sn, PPV and NPV of 87.2%, 91.5%, 89.6% and 98.6%, respectively. The NPV for predicting adenomas in diminutive rectosigmoid polyps (n = 150) was 96.6% and 95% with MS and NICE respectively. The calculated accuracy of post-polypectomy surveillance for MS group was 98.2% (167 out of 170) and for NICE group was 92.1% (139 out of 151). CONCLUSION The MS classification outperformed the NICE classification in differentiating neoplastic polyps and predicting endoscopic resectability. Both classifications met ASGE PIVI thresholds.

False sense of security: a case of retroperitoneal perforation after colonic EMR

re 1. A, Laterally spreading tumor at the rectosigmoid junction. B, Suspected site of perforation, with a whitish circular ring and bluish base. losure of perforation with 6 hemoclips. D, Resection of remainder of the polyp. E, Resected specimen showing the target sign. F, Histology slide ing the muscularis propria, confirming the perforation. G, Abdominal CT view showing no evidence of perforation. Yellow arrow indicates scopic clips.

A prospective randomised controlled trial comparing carbon dioxide and air insufflation during ERCP: Is it worth the pain?

Carbon dioxide (CO2) insufflation has been shown to reduce post‐procedural pain in endoscopic procedures such as flexible sigmoidoscopy and colonoscopy due to improved absorption via the gastrointestinal tract and subsequent reduction in bowel distension. The benefit of CO2 insufflation in upper endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP) is less clear.