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Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials.

BACKGROUND AND STUDY AIMS Precut papillotomy is considered a risk factor for endoscopic retrograde cholangiopancreatography (ERCP)-related complications; however whether the complication risk is due to precut itself or to the prior prolonged attempts is still debated; therefore, early precut implementation has been suggested to reduce the complication rate. We conducted a meta-analysis of randomized controlled trials (RCTs) comparing cannulation and complication rates of early precut implementation with persistent attempts by the standard approach. METHODS RCTs that compared cannulation and complication rates of the early precut implementation and of persistent attempts by the standard approach were included. Summary effect sizes were estimated by odds ratio (OR) with a random-effects model and by Peto OR. RESULTS Six RCTs with a total of 966 subjects met the inclusion criteria. Overall cannulation rates were 90 % in both randomization groups (OR 1.20; 95 % confidence interval [CI] 0.54 - 2.69). Post-ERCP pancreatitis developed in 2.5 % of patients randomized to the early precut groups and in 5.3 % of patients from the persistent attempts groups (OR 0.47; 95 %CI 0.24 - 0.91). The overall complication rates, considering pancreatitis, bleeding, cholangitis, and perforation rates, were 5.0 % in the early precut groups and 6.3 % in the persistent attempts groups (OR 0.78; 95 %CI 0.44 - 1.37). CONCLUSIONS RCTs that investigated the issue of timing of the precut procedure were limited. Current evidence suggests that in experienced hands the early implementation of precut and persistent cannulation attempts have similar overall cannulation rates; early precut implementation reduces post-ERCP pancreatitis risk but not the overall complication rate. Further studies are needed to confirm these findings.

Can a Wire-Guided Cannulation Technique Increase Bile Duct Cannulation Rate and Prevent Post-ERCP Pancreatitis?: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES:The most common technique used to achieve primary deep biliary cannulation is the standard contrast-assisted method. To increase the success rate and reduce the risk of complications, a wire-guided cannulation strategy has been proposed. Prospective studies provided conflicting results as to whether the wire-guided cannulation technique increases the cannulation rate and reduces post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis risk compared with the standard method. The objective of this study was to carry out a meta-analysis of randomized controlled trials (RCTs) that compares primary biliary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique.METHODS:Literature searches of electronic databases and online clinical trial registers up to March 2009 were conducted to identify RCTs comparing primary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. A meta-analysis of these clinical trials was performed.RESULTS:Five RCTs were included. Overall, the primary cannulation rates reported with the wire-guided cannulation technique and the standard method were 85.3 and 74.9%, respectively. The pooled analysis of all the selected studies comparing the wire-guided cannulation technique with the standard method yielded an odds ratio (OR) of 2.05 (95% confidence interval (CI): 1.27–3.31). The pooled analysis comparing the post-ERCP pancreatitis rates for the wire-guided-cannulation groups with those for the standard-method groups yielded an OR of 0.23 (95% CI: 0.13–0.41).CONCLUSIONS:This meta-analysis shows that the wire-guided technique increases the primary cannulation rate and reduces the risk of post-ERCP pancreatitis compared with the standard contrast-injection method. Further large, well-performed, randomized controlled studies are needed to confirm these findings.

Does Stent Placement for Advanced Colon Cancer Increase the Risk of Perforation During Bevacizumab-Based Therapy?

BACKGROUND & AIMS Data on the safety of bevacizumab-based therapies for patients carrying a self-expandable metallic stent (SEMS) for occlusive colon cancer are lacking. We report 2 cases of colon perforation observed in our case series of patients with SEMS for occlusive colon cancer. METHODS Patients with occlusive symptoms caused by colon cancer received a colonic stent under endoscopic and radiologic guidance. RESULTS Over a 10-month period, 28 patients with occlusive colon cancer were treated with stent placement. The stent was placed as a bridge to surgery in 12 patients who were treated surgically within 4 to 78 days after the endoscopic procedures, without any stent-related complications. Seven patients did not receive any other antitumor treatment as a result of concomitant comorbidities. Nine patients with both primary tumor and metastatic lesions were treated with medical therapy. Over a median follow-up period of 131 days colonic perforation occurred in the 2 patients treated with a combination of capecitabine and oxaliplatin plus bevacizumab. CONCLUSIONS Further studies are needed to clarify whether SEMS placement increases the risk of perforation caused by bevacizumab-based therapies.

EFFECTS OF PROBIOTICS FOR THE PREVENTION AND TREATMENT OF RADIATION-INDUCED DIARRHEA

Background and Aims Probiotic supplementation seems to provide beneficial effects in the prevention and treatment of radiation-induced diarrhea. We performed a systematic review and meta-analysis to estimate the efficacy of probiotic supplementation for prevention and treatment of radiation-induced diarrhea. Methods Two reviewers independently searched PubMed, EMBASE, Cochrane Library, Google Scholar and on-line clinical trials registers (up to January 2009) for randomized controlled trials that evaluated the efficacy of probiotic supplementation for the prevention and treatment of radiation-induced diarrhea. Each clinical trial was separately evaluated for study characteristics, methodologic quality and outcomes. Results of the randomized controlled trials were pooled in a meta-analysis. Results Four randomized controlled trials were included. Three clinical trials, with a total of 632 subjects, evaluated the preventive effects of probiotic supplementation and 1 study evaluated the therapeutic role. Random effects meta-analysis of the preventive trials did not show significant differences between probiotic supplementation and control groups (odds ratio 0.47; 95% confidence interval: 0.13-1.67). However, the few available trials and the presence of significant clinical and statistical heterogeneity limited the analysis. Similarly, the therapeutic clinical trial did not show significant differences between active and placebo groups. No major adverse events owing to probiotic supplementation were reported in any study. Conclusions Probiotic supplementation showed beneficial effect in the prevention and treatment of radiation-induced diarrhea in experimental animal studies. Encouraging results have been observed in humans; however, the few available clinical studies do not allow firm conclusions. More well-performed, randomized placebo-controlled studies are needed.

The role of K-ras gene mutation analysis in EUS-guided FNA cytology specimens for the differential diagnosis of pancreatic solid masses: a meta-analysis of prospective studies

BACKGROUND Differential diagnosis of pancreatic solid masses with EUS-guided FNA (EUS-FNA) is still challenging in about 15% of cases. Mutation of the K-ras gene is present in over 75% of pancreatic adenocarcinomas (PADC). OBJECTIVE To assess the accuracy of K-ras gene mutation analysis for diagnosing PADC. DESIGN We systematically searched the electronic databases for relevant studies published. Data from selected studies underwent meta-analysis by use of a bivariate model providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. SETTING Meta-analysis of 8 prospective studies. PATIENTS Total of 931 patients undergoing EUS-FNA for diagnosis of pancreatic solid masses. INTERVENTION K-ras mutation analysis. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy of K-ras mutation analysis and of combined diagnostic strategy by using EUS-FNA and K-ras mutation analysis in the diagnosis of PADC. RESULTS The pooled sensitivity of EUS-FNA for the differential diagnosis of PADC was 80.6%, and the specificity was 97%. Estimated sensitivity and specificity were 76.8% and 93.3% for K-ras gene analysis, respectively, and 88.7% and 92% for combined EUS-FNA plus K-ras mutation analysis. Overall, K-ras mutation testing applied to cases that were inconclusive by EUS-FNA reduced the false-negative rate by 55.6%, with a false-positive rate of 10.7%. Not repeating EUS-FNA in cases in which mutation testing of the K-ras gene is inconclusive would reduce the repeat-biopsy rate from 12.5% to 6.8%. LIMITATIONS Small number of studies and between-study heterogeneity. CONCLUSION K-ras mutation analysis can be useful in the diagnostic work-up of pancreatic masses, in particular when tissue obtained by EUS-FNA is insufficient, and the diagnosis inconclusive.

Diagnosis and management of gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopic pattern and, for uncertain cases, on histology. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way, the so called honeycomb stomach. The histological pattern, although not pathognomonic, is characterized by four alterations: vascular ectasia of mucosal capillaries, focal thrombosis, spindle cell proliferation and fibrohyalinosis, which consist of homogeneous substance around the ectatic capillaries of the lamina propria. The main differential diagnosis is with Portal Hypertensive Gastropathy, that can frequently co-exists, since about 30% of patients with GAVE co-present a liver cirrhosis. Autoimmune disorders, mainly represented by Reynauds phenomenon and sclerodactyly, are co-present in about 60% of patients with GAVE; other autoimmune and connective tissue disorders are occasionally reported such as Sjogrens syndrome, systemic lupus erythematosus, primary biliary cirrhosis and systemic sclerosis. In the remaining cases, GAVE syndrome has been described in patients with chronic renal failure, bone marrow transplantation and cardiac diseases. The pathogenesis of GAVE is still obscure and many hypotheses have been proposed such as mechanical stress, humoural and autoimmune factors and hemodynamic alterations. In the last two decades, many therapeutic options have been proposed including surgical, endoscopic and medical choices. Medical therapy has not clearly shown satisfactory results and surgery should only be considered for refractory severe cases, since this approach has significant mortality and morbidity risks, especially in the setting of portal hypertension and liver cirrhosis. Endoscopic therapy, particularly treatment with Argon Plasma Coagulation, has shown to be as effective and also safer than surgery, and should be considered the first-line treatment for patients with GAVE-related bleeding.

Endoscopic Argon Plasma Coagulation for the Treatment of Gastric Antral Vascular Ectasia-Related Bleeding in Patients with Liver Cirrhosis

Background and Aim: Gastric antral vascular ectasia (GAVE) is a cause of bleeding in patients with liver cirrhosis. Argon plasma coagulation (APC) is the most used endoscopic treatment for GAVE-related bleeding. Treatment failures have been described in patients with haemorrhagic diathesis; post-procedure complications include haemorrhages and septicaemia. The aim of the study was to evaluate efficacy and safety of APC treatment of GAVE-related bleeding in patients with liver cirrhosis. Methods: Patients included were suffering from GAVE-related bleeding and liver cirrhosis. APC treatment was performed until eradication. Resolution of transfusion-dependent anaemia and evaluation of complications were the primary outcomes. Results: 20 patients (16 Child C and 4 Child B) were enrolled and prospectively followed for a mean period of 28 months. GAVE eradication was achieved in all patients after a median of 3 sessions (range 1–10). Resolution of anaemia was achieved in 18 patients. Six patients had relapse of GAVE after a mean of 7.7 months, successfully retreated by APC. Hyperplastic polyps developed in 3 patients causing active bleeding in 2 cases. Five patients had liver transplants and 1 had a relapse of GAVE after transplantation. Conclusion: APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.

Treatment of Helicobacter pylori infection.

#### Summary points Helicobacter pylori is one of the most common human infections, and about half of the world’s population carries this organism. Since its discovery in 1984, H pylori has been recognised as a major cause of several upper gastrointestinal diseases.1 2 As with other chronic infectious diseases, several antibiotics must be given simultaneously and sometimes repeated courses of different combinations of antibiotics are needed to eradicate H pylori . Eradicating H pylori is still a challenge, however, because of the rapidly increasing prevalence of multidrug resistant strains worldwide. In recent years, several randomised controlled trials and meta-analyses have proposed new regimens and treatment strategies for H pylori infection. This review will discuss the available treatment strategies for H pylori infection and help identify the most effective one. The prevalence of H pylori varies widely, with more than 80% of adults being infected in Japan and South America compared with around 40% in the United Kingdom and 20% in Scandinavia.3 Epidemiological evidence suggests that many people acquire the infection in childhood—social deprivation, household crowding, and number of siblings are important risk factors. The prevalence of infection increases with age, although this may be largely a cohort effect. Poorer socioeconomic conditions 60 …

Randomised clinical trial: preventive treatment with topical rectal beclomethasone dipropionate reduces post‐radiation risk of bleeding in patients irradiated for prostate cancer

Aliment Pharmacol Ther 2011; 34: 628–637

Side-viewing endoscope for colonic self-expandable metal stenting in patients with malignant colonic obstruction

Malignant colon obstruction is a medical emergency and endoscopic decompression, achieved by self-expandable metal stent placement, has been broadly used for both palliation in patients with advanced, nonresectable carcinoma and as a bridge to surgery in those patients with resectable disease. We propose stent insertion assisted by a side-viewing endoscope, in sharply angulated and remarkably stenotic lesions located at the distal sigmoid. Endoscopists should consider, at least for lesions situated in the distal colon, the insertion of a side-viewing endoscope for stenting of technically difficult cases of malignant intestinal obstruction.