Sameer Siddique

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

AIM To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy. METHODS MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. RESULTS Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%. CONCLUSION Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

Miralax With Gatorade for Bowel Preparation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES:Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax–Gatorade (M–G) vs. PEG for bowel preparation before colonoscopy.METHODS:Multiple databases were searched (January 2014). RCTs on adults comparing M–G (238–255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8–4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models.RESULTS:Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M–G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43–0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88–10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M–G vs. split-dose PEG.CONCLUSIONS:M–G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M–G for bowel preparation before colonoscopy.

Response to Zhang

a priori for all analyses, and then the alternative model is performed as a sensitivity analysis. Moreover, when we evaluated the treatment regimes of each study, we found great variations across studies. So the heterogeneity across studies is obvious, a random model might be appropriate to pool data. When we used the same data to perform the meta-analysis with a random model, we found no statistically signifi cant diff erences between M-G and PEG in satisfactory bowel preparations (OR=0.67; 95%CI: 0.37–1.22; P =0.19), as shown in Figure 1 . Moreover, the P value is only 0.04 (slightly <0.05) in fi xed models, so we could not come to a defi nite conclusion that PEG is superior to M-G either. In addition, the meta-analysis conducted by Siddique et al. found no signifi cant difference between PEG and M-G in polyp detection, side eff ects, nausea, cramping, and bloating ( 1 ). On the basis of the available evidences, the debate of whether PEG is superior to M-G is not over. When abundant randomized controlled trials are available, a dose-dependent meta-analysis and a Bayesian network meta-analysis might provide comprehensive views of whether PEG is superior to M-G.

Response to Syed

To the Editor: We thank you for the interesting article by Siddique et al. ( 1 ) on the meta-analysis comparing Miralax with Gatorade (M–G) with polyethylene glycol (PEG). Th ere are two areas that need to be further looked at. One being that the current guidelines strongly recommend split-dose bowelcleansing regime over full dose ( 2 ). Many studies have shown that split-dose preparation provides higher effi cacy for adenoma detection. Th e meta-analysis includes articles by Gerard et al. and McKenna et al. that use a full-dose preparation. Both articles used full-dose preparation the day before a morning colonoscopy; however, current guidelines encourage an acceptable alternative to split-dosing is a same-day regime for patients undergoing an aft ernoon colonoscopy ( 2 ). Th e longer runway time also attributes to poorer adenoma detection. Another issue that rose while reading the meta-analysis was lack of exclusion criteria and discrepancy between patients studied. Current Food and Drug Administration-approved preparations strongly recommend that bowel-cleansing regimes should take into account comorbidities and outpatient medications. Th ere are patient-related factors, as well as procedure-related factors that are predictive of bowel preparation quality, independent of the colon-cleansing agent. Patient-related factors that were not discussed in Siddique et al. include comorbidities such as diabetes and outpatient medications. Diabetes may have been an exclusion criteria in the articles analyzed in this meta-analysis because it has been shown to impair colonic and gastrointestinal transit time, but it is not specifi ed in the article. Many medications can also slow transit time, and patients taking more than eight active prescription medications is a strong indicator for poor bowel preparation ( 3 ). Another factor that can aff ect bowel preparation is inpatient vs. outpatient status. All articles used in the meta-analysis include outpatients, except Hjelkrem et al., which gathers patients from a tertiary care center. Inpatient status has oft en been associated with poorer bowel preparation because of prolonged immobility of these patients, as well as their comorbid illnesses ( 3 ). Also, Romero and Mahadeva ( 3 ) fi nd that males are 1.6 times more likely to have poor bowel preparations when compared with female patients . Many randomized clinical trials do in fact show PEG is superior to M–G; however, all factors should be considered when a meta-analysis is done comparing these studies.

Response to Gerard et al.

REFERENCES 1. Siddique S , Lopez KT , Hinds AM et al. Miralax with gatorade for bowel preparation: a metaanalysis of randomized controlled trials . Am J Gastroenterol 2014 ; 109 : 1566 – 74 . 2. Gerard DP , Holden JL , Foster DB et al. Randomized trial of Gatorade/polyethylene glycol with or without bisacodyl and NuLYTELY for colonoscopy preparation . Clin Transl Gastroenterol 2012 ; 3 : 1 – 9 .