Tarek Sawas

The course of achalasia one to four decades after initial treatment.

Most follow‐up studies of achalasia are limited to <5 years.

Safety and efficacy of coaxial lumen-apposing metal stents in the management of refractory gastrointestinal luminal strictures: a multicenter study

Background and aims  Benign gastrointestinal (GI) strictures are often refractory to standard endoscopic interventions. Fully covered coaxial lumen-apposing metal stents (LAMS) have emerged as a novel therapy for these strictures. The aim of this study was to evaluate the safety and efficacy of LAMS for refractory GI strictures. Patients and methods  A retrospective analysis was performed for patients who underwent LAMS placement for benign luminal strictures in three US centers between January 2014 and December 2016. The primary outcomes were technical success and initial clinical success of LAMS placement. Secondary outcomes were stent migration, rate of re-intervention, and adverse events. Results  A total of 49 patients underwent 56 LAMS placement procedures. Previous treatment had failed in 39 patients (79.6 %), and anastomotic strictures were the indication in 77.6 % (38/49), with the most common site being gastrojejunal (34.7 % [17/49]). Technical success was achieved in all procedures and initial clinical success was achieved in 96.4 % of all procedures (54/56). Patient initial clinical success was 95.9 % (47/49). Stent migration occurred in 17.9 % of procedures, and was more likely to occur at sites in the lower GI tract ( P  = 0.02). The mean stent dwell time was 100.6 days, and the mean follow-up was 169.8 days. Minor adverse events, not requiring hospitalization, occurred in 33.9 % of procedures, including subsequent stricture progression (10.7 %). In cases where LAMS were removed, mean follow-up time was 102.2 days. The re-intervention rate was 75 % at 300 days follow-up after stent removal. Of the LAMS placed at anastomotic strictures, 36.4 % required re-intervention, with approximately two-thirds of these re-interventions requiring placement of a new stent or surgery. Conclusion  LAMS placement was successful for the management of refractory GI strictures, with good technical and initial clinical success rates. However, re-intervention rates after LAMS removal were high, and many strictures were not resolved by an extended period of stenting with these coaxial stents. LAMS placement offers additional therapeutic options and in selected cases might be considered a destination therapy for patients with recalcitrant benign strictures.

Outcomes of oesophageal self-dilation for patients with refractory benign oesophageal strictures

Current management of refractory benign oesophageal strictures with endoscopic dilations and stenting leads to resolution of dysphagia in only 30% of patients. Oesophageal self‐dilation may be an alternative.

Higher Rate of Barrett’s Detection in the First Year After Successful Endoscopic Therapy: Meta-analysis

BACKGROUND: Endoscopic eradication therapy (EET) is highly effective in treating dysplastic Barretts esophagus (BE). Current surveillance intervals after complete remission of intestinal metaplasia (CRIM) are based on expert opinion. We performed a meta‐analysis to compare BE detection in the first year to the subsequent ones METHODS: We searched MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials through 1 August 2017 for studies reporting IM and neoplasia detection after CRIM. Pooled incidence rate (IR) of IM detection was calculated for each year after CRIM. We compared IM, dysplasia, and high grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) detection in the first year after CRIM to the years after. RESULTS: Twenty two studies were included involving 1973 patients with follow‐up of 5176 patient‐years. IM detection IR per patient‐year in the 1st year was 12% (95% CI: 8‐17%), in the 2nd year 7% (95% CI: 4‐11%), and in the 3rd year 3% (95% CI: 1‐7%). IM detection rate in the first year was significantly higher compared to the years after (relative risk (RR) 1.8 (95% CI: 1.29‐2.49)). Dysplasia detection IR in the first year after achieving CRIM was 3% per patient‐year (95% CI: 2‐5%). Dysplasia detection IR after the first year was 1% (95% CI: 1‐2%) and significantly higher in the first year compared to the years after (RR: 1.92 (95% CI: 1.32‐2.8). HGD/EAC detection was 1 %/patient‐year (95% CI: 0‐2%) in the first year after CRIM compared to 0%/patient‐year (95% CI: 0‐1%) in subsequent years. HGD/EAC IR was higher in the first year (RR: 1.58 (95% CI: 0.94‐2.65)). CONCLUSION: Neoplasia detection after successful treatment of BE appears more common within the first year of surveillance. This appears to be due to incompletely treated prevalent rather than recurrent disease. More intensive surveillance in the first year following CRIM is warranted.

Sphincterotomy with endoscopic biliary drainage for severe acute cholangitis: a meta-analysis

Aims To investigate the role of endoscopic sphincterotomy (ES) with endoscopic biliary drainage (EBD) in acute severe obstructive cholangitis management by performing a meta-analysis of controlled trials. Method We searched PubMed and Embase for controlled studies that compared endoscopic drainage with ES versus Non-ES in acute obstructive cholangitis. Two reviewers selected the studies and extracted the data. Disagreement was addressed by a third reviewer. Heterogeneity of the studies was analyzed by Cochran’s Q statistics. A Mantel–Haenszel risk ratio was calculated utilizing a random effects model. Results Four controlled studies met our inclusion criteria with 392 participants (201 ES, 191 Non-ES). The outcomes were drainage insertion success rate, drainage effectiveness, post drainage pancreatitis, bleeding, procedure duration, perforation, cholecystitis, and 30-day mortality. Drainage insertion success rate was identical in both groups (RR: 1.00, 95 %CI% 0.96 – 1.04). Effective drainage was not significantly different (RR: 1.11, 95 %CI 0.73 – 1.7). There was no significant difference in the incidence of pancreatitis post EBD between the ES and Non-ES groups at 3 % and 4 %, respectively (RR: 0.73, 95 %CI 0.24 – 2.27). However, there was a significant increase in post EBD bleeding with ES compared to Non-ES (RR: 8.58, 95 %CI 2.03 – 36.34). Thirty-day mortality was similar between ES and Non-ES groups at 0.7 % and 1 %, respectively (RR: 0.5, 95 %CI 0.05 – 5.28). Conclusion Our findings show that EBD without ES is an effective drainage technique and carries less risk for post procedure bleeding. Patients who are critically ill and have coagulopathy should be spared from undergoing ES in the acute phase.

Response to Zhou et al.

To the editor: We are grateful to Drs. Zhang, Wu, Zhou and Xu for their additional analysis of our data with their wellperformed cumulative meta-analysis. With the findings that their analysis confirms our findings, particularly with regard to intestinal metaplasia and dysplasia, it helps us to reinforce the need for careful inspection and sampling of Barrett’s mucosa before and early after radiofrequency ablation to rule out the presence of prevalent lesions. This cumulative analysis also notes, however, that clear proof that high grade dysplasia (HGD)/cancer detection within the first year of endoscopic therapy is not equal to or greater than that found in subsequent endoscopies is also important. Nevertheless, the practical point is that, even if the rates of developing HGD/cancer in the first year are close to that of subsequent years, it is more than enough reason to apply the principle that early and careful endoscopic followup after ablation is performed to find undetected advanced lesions. Whether our data and this additional analysis will lead to guideline changes merits further exploration.

Superiority of metal stents in the endoscopic management of pancreatic walled-off necrosis: inferences from recent systematic reviews and meta-analyses of the literature

We read with great interest the systematic review and metaanalysis published in the journal by Panwar et al. [1] regarding metal stents versus plastic stents for the management of pancreatic fluid collections (PFC), and appreciate the opportunity to comment on this interesting and important question. Considering the importance of the topic and the current unmet clinical needs in this setting, our group has separately been evaluating these questions, and we believe that we have followed a different, albeit complementary methodology emanating from our clinical experience in the management of pancreatic fluid collections in a large quaternary referral center [2, 3]. Hence, the two reviews combined provide a cohesive summary to guide clinical care. Panwar et al. [1] restricted their inclusion criteria to studies that directly compared metal versus plastic stents. In our meta-analysis, we included single-arm non-comparative studies. Case series, although are usually at higher risk of bias, are important to evaluate adverse events. Despite the heterogeneity of defining walled-off necrosis (WON) in case series, we believe adverse effects are likely less related to the type of PFC and more closely related to the type of deployed stent. We were also able to evaluate the methodological quality of case series. Until recently, the literature lacked tools for this assessment. We had recently developed a simple and reproducible tool that can be used for this purpose. We have adapted the New-Castle Ottawa (NOS) scale [4] by removing items that relate to comparability and adjustment and retained items that focused on selection, representativeness of cases and ascertainment of outcomes and exposure. This has resulted in five items (Table 1) in the form of questions with a binary response (yes or no) to indicate whether the item is suggestive or not of major limitations. We considered the quality of the report good when all five criteria were fulfilled, moderate when four were fulfilled, and poor when three or less were fulfilled. This tool has been consistently applied in published systematic reviews [3, 5–9]. This approach permitted a granular examination of different complications associated with each type of stents. Therefore, we were able to demonstrate that metal stents were associated with lower rates of bleeding, a trend towards lower perforation and stent occlusion, but a higher rate of stent migration. Panwar et al. [1] selected studies that included both WON as well as pseudocysts. We restricted the a priori inclusion criteria to studies evaluating WON alone, and excluded those which did not provide sufficient data to allow application of the revised Atlanta criteria to their cohorts [10]. We also excluded studies that used concomitant percutaneous or surgical drainage simultaneously with endoscopic treatment so that outcomes could be attributed more confidently to the types of stent used across the different studies. Panwar et al. [1] found that metal stents were superior in decreasing adverse events risk in sepsis-related and unrelated events; which is not surprising. This may be related to the concomitant debridement that usually accompanies the placement of metal stents draining the WON. While a signal may be inferred from these two recent meta-analyses regarding the superiority of metal stents, prospective randomized controlled trials are needed to answer all of these questions. Since conducting such trial is likely to be challenging, and may not occur soon, data from these two meta-analyses represent an objective evaluation of the best available evidence regarding important technical aspects of WON endoscopic treatment. * Barham K. Abu Dayyeh abudayyeh.barham@mayo.edu

Transcatheter Aortic Valve Replacement in Patients with Pure Native Aortic Valve Regurgitation: A Systematic Review and Meta-analysis

This systematic review and meta‐analysis sought to summarize the available evidence on the use of transcatheter aortic valve replacement (TAVR) in patients with Native Aortic Valve Regurgitation (NAVR) and compare outcomes between first and second generation valves. Owing to the improvements in transcatheter heart valve design and procedural success, TAVR has become increasingly performed in broader aortic valve pathologies. We searched Medline, Embase, Cochrane, and Scopus databases from 2007 to 2018 and performed a systematic review on reports with at least 10 patients with aortic valve regurgitation undergoing TAVR procedure. The main outcome of interest was all‐cause mortality at 30 days. A total of 638 patients across 12 studies were included. Mean age ranged from 68 to 84. Society of Thoracic Surgeons score ranged from 5.4% to 13.1% and Logistic EuroSCORE ranged from 18.2% to 33%. The incidence rate of all‐cause mortality at 30 days was found to be 11% (95% CI 7%‐16%; I2 = 20.86%). All‐cause mortality at 30 days for first generation valves had an incidence rate of 15% (95% CI 10%‐20%; I2 = 10%) compared to 7% (95% CI 3%‐13%; I2 = 37%) in second generation valves with subgroup interaction analysis P = 0.059. Device success incidence rate in second generation valves was 92% (95% CI 83%‐99%; I2 = 67%) vs 68% (95% CI 59%‐77%; I2 = 53%) in first generation valves with P = 0.001. TAVR appears to be a feasible treatment choice for NAVR patients at high risk for surgical valve replacement. Second generation valves show promising results in terms of short‐term outcomes.