Weiguang Qiao

Tumor Necrosis Factor Alpha Blocking Agents as Treatment for Ulcerative Colitis Intolerant or Refractory to Conventional Medical Therapy: A Meta-Analysis

Background Efficacy of tumor necrosis factor alpha (TNF-α) blockers for treatment of ulcerative colitis that is unresponsive to conventional therapy is unclear due to recent studies yielding conflicting results. Aim To assess the efficacy and safety of anti-TNF-α agents for treatment of ulcerative colitis patients who were intolerant or refractory to conventional medical therapy. Methods Pubmed, Embase, and the Cochrane database were searched. Analysis was performed on randomized controlled trials that assessed anti-TNF-α therapy on ulcerative colitis patients that had previously failed therapy with corticosteroids and/or immunosuppressants. The primary outcome focused on was the frequency of patients that achieved clinical remission. Further trial outcomes of interest included rates of remission without patient use of corticosteroids during the trial, extent of mucosal healing, and the number of cases that resulted in colectomy and serious side effects. Results Eight trials from seven studies (n = 2122) met the inclusion criteria and were thus included during analysis. TNF-α blockers demonstrated clinical benefit as compared to placebo control as evidenced by an increased frequency of clinical remission (p<0.00001), steroid-free remission (p = 0.01), endoscopic remission (p<0.00001) and a decrease in frequency of colectomy (p = 0.03). No difference was found concerning serious side effects (p = 0.05). Three small trials (n = 57) comparing infliximab to corticosteroid treatment, showed no difference in frequency of clinical remission (p = 0.93), mucosal healing (p = 0.80), and requirement for a colectomy (p = 0.49). One trial compared infliximab to cyclosporine (n = 115), wherein no difference was found in terms of mucosal healing (p = 0.85), colectomy frequency (p = 0.60) and serious side effects (p = 0.23). Conclusion TNF-α blockers are effective and safe therapies for the induction and maintenance of long-term remission and prevention of treatment by colectomy for patients with refractory ulcerative colitis where conventional treatment was previously ineffective. Furthermore, infliximab and cyclosporine were found to be comparable for treating acute severe steroid-refractory ulcerative colitis.

Predictors of Extubation Failure in Neurocritical Patients Identified by a Systematic Review and Meta-Analysis

Background Prediction of extubation failure, particularly in neurocritical patients, is unique and controversial. We conducted a systematic review and meta-analysis to identify the risk factors for extubation failure in these patients. Methods A literature search of databases (MEDLINE, EMBASE, the Cochrane Library, and Web of Science) was performed up to August of 2013 to identify trials that evaluated extubation failure predictors. Included trials were either prospective or retrospective cohort studies. Results Nine studies involving 928 participants were included. The systematic review and meta-analysis revealed that the following were predictive for extubation failure: pneumonia, atelectasis, mechanical ventilation of >24 h, a low Glasgow Coma Scale score (7–9T) (OR = 4.96, 95% CI = 1.61–15.26, P = 0.005), the inability to follow commands (OR = 2.07, 95% CI = 1.15–3.71, P = 0.02), especially the command to close the eyes, thick secretion, and no intact gag reflex. Meanwhile, the following were not predictive for extubation failure: sex, secretion volume, coughing upon suctioning, and the inability to follow one command among showing two fingers, wiggling the toes, or coughing on command. Additionally, some traditional weaning parameters were shown to poorly predict extubation failure in neurocritical patients. Conclusions Besides pneumonia, atelectasis, and the duration of mechanical ventilation, other factors that should be taken into consideration in the prediction of extubation failure when neurocritical patients are weaned from tracheal intubation include neurologic abilities (Glasgow Coma Scale score and following commands), the secretion texture, and the presence of a gag reflex.

Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement

AbstractThe evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14–17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.

The Effect of Virtual Endoscopy Simulator Training on Novices: A Systematic Review

Background Advances in virtual endoscopy simulators have paralleled an interest in medical simulation for gastrointestinal endoscopy training. Objective The primary objective was to determine whether the virtual endoscopy simulator training could improve the performance of novices. Design A systematic review. Setting Randomized controlled trials (RCTs) that compared virtual endoscopy simulator training with bedside teaching or any other intervention for novices were collected. Patients Novice endoscopists. Interventions The PRISMA statement was followed during the course of the research. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched (up to July 2013). Data extraction and assessment were independently performed. Main outcome measurements Independent procedure completion, total procedure time and required assistance. Results Fifteen studies (n = 354) were eligible for inclusion: 9 studies designed for colonoscopy training, 6 for gastroscopy training. For gastroscopy training, procedure completed independently was reported in 87.7% of participants in simulator training group compared to 70.0% of participants in control group (1 study; 22 participants; RR 1.25; 95% CI 1.13–1.39; P<0.0001). For colonoscopy training, procedure completed independently was reported in 89.3% of participants in simulator training group compared to 88.9% of participants in control group (7 study; 163 participants; RR 1.10; 95% CI 0.88–1.37; P = 0.41; I 2 = 85%). Limitations The included studies are quite in-homogeneous with respect to training schedule and procedure. Conclusions Virtual endoscopy simulator training might be effective for gastroscopy, but so far no data is available to support this for colonoscopy.

Effects of probucol on restenosis after percutaneous coronary intervention: a systematic review and meta-analysis.

Background Restenosis after percutaneous coronary intervention (PCI) is a remained clinical problem which limits long-term success of PCI. Although there was recognition that probucol in treating restenosis after percutaneous transluminal coronary angioplasty, the efficacy of probucol on restenosis after stent-implantation is controversial. So this meta-analysis was conducted to investigate the association between probucol and late restenosis. Methods Articles were assessed by four trained investigators, with divergences resolved by consensus. PubMed, EMBASE, ScienceDirect and the Cochrane Central Register of clinical trials were searched for pertinent studies. Inclusion criteria were random allocated to treatment and a comparison of probucol-treated patients and control patients (not treated with lipid-lowering drug) undergoing PCI. Results Fifteen studies with 859 subjects were analyzed. Major outcome, binary angiographic restenosis defined as >50% stenosis upon follow-up angiography, was significantly decreased with probucol treatment (RR = 0.59 [0.43, 0.80] among vessels, P = 0.0007; and RR = 0.52 [0.40, 0.68] among patients, P<0.00001). Probucol also increased the minimal luminal diameter (SMD = 0.45 [0.30, 0.61], P<0.00001) and decreased late loss upon follow-up after 6 months (SMD = -0.41 [-0.60, -0.22], P<0.0001). Moreover, there was a significantly lower incidence of major adverse cardiac events (MACE) in the probucol group than control group (RR = 0.69 [0.51, 0.93], P = 0.01). Conclusion Probucol is more than a lipid-lowering drug. It is also effective in reducing the risk of restenosis and incidence of MACE after PCI.

Role of transgastric natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin (with videos)

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies. OBJECTIVE The aim of this study was to assess the feasibility and efficacy of applying transgastric NOTES to diagnose patients with ascites of unknown origin. DESIGN Prospective study. SETTING Two university and teaching hospitals. PATIENTS Patients with ascites of unknown origin. INTERVENTIONS Diagnostic transgastric NOTES. MAIN OUTCOME MEASUREMENTS Characteristic of ascites cases, conditions of the abdominal cavity, diagnostic accuracy, adverse events, and follow-up time. RESULTS Transgastric NOTES was performed successfully in 78 patients with ascites of unknown origin, and 72 cases (92.3%) were clearly diagnosed. They included malignant tumors (39 cases), tuberculous peritonitis (28 cases), chronic hepatic inflammation (3 cases), necrotizing lymphadenitis (1 case), and eosinophilic serositis of the small intestine (1 case). In addition, there were 6 nondiagnostic cases, and no severe adverse events were found. LIMITATIONS Nonrandomized control analysis. CONCLUSION Transgastric NOTES in combination with biopsy can elucidate the causes of ascites of unknown origin in the majority of cases. Therefore, it is a feasible and effective approach to access the peritoneal cavity and also a valuable modality to detect the cause of diseases with ascites of unknown origin.

Results of a second examination of the right side of the colon in screening and surveillance colonoscopy: a systematic review and meta-analysis

Background Screening colonoscopy is less effective in preventing proximal colon cancers than distal colon cancers. A repeat examination of the right side of the colon may increase the lesion detection. The study aimed to assess the results of a second examination of the right side of the colon with forward-view or retroflexion colonoscopy performed immediately after the initial examination. Materials and methods We carried out a meta-analysis of all primary studies that performed a second examination of the right side of the colon with forward-view or retroflexion colonoscopy performed immediately after the initial examination. Results Six cohorts of five studies with 4155 participants were included in the final study. The adenoma detection rate (ADR) was 28.8% of the combined examinations compared with 24.1% of the single examination (P<0.001), for a pooled odds ratio of 1.34 [95% confidence interval (CI): 1.13–1.59]. For retroflexion assessment, ADR was achieved in 25.4% patients in the combined group, compared with 22.3% in the single examination group (P=0.002), for a pooled odds ratio of 1.19 (95% CI: 1.06–1.33). For forward-view assessment, ADR was achieved in 46.0% patients in the combined group, compared with 33.5% in the single examination group (P<0.001), for a pooled odds ratio of 1.76 (95% CI: 1.40–2.22). Conclusion For ADR of the right side of the colon, a repeat examination could lead to a modest improvement in the detection of lesions in the proximal colon, irrespective of forward-view or retroflexion assessment.

Sedation With Propofol Has No Effect on Capsule Endoscopy Completion Rates: A Prospective Single-Center Study

AbstractPatients who need both capsule endoscopy (CE) and colonoscopy often undergo both examinations on the same day to avoid repeated bowel preparation and fasting. Sedation can relieve pain and is commonly used for colonoscopies but may influence the CE completion rate.To determine whether sedation with propofol influences the completion rate and small-bowel transit time (SBTT) of CE.From July 2014 to December 2014, patients (18–65 years old) who needed both CE and colonoscopy were assessed consecutively for enrollment in our study. Colonoscopies were performed with or without sedation based on patient preferences on the day of capsule ingestion. The completion rate, SBTT, and diagnostic yield of CEs were recorded. Patients’ satisfaction and pain scores were also recorded.Sedation with propofol had no significant effect on CE completion rates (83.3% sedation group vs 81.8% nonsedation group, P = 0.86) but was associated with increased SBTT (403.6 ± 160.3 sedation group vs 334.5 ± 134.4 nonsedation group, P = 0.006). The diagnostic yields in the sedation and nonsedation groups were 69.4% and 65.9%, respectively (P = 0.74). The median satisfaction scores were 8.6 in the sedation group and 3.5 in the nonsedation group (P < 0.001). Median pain scores were 1.4 in the sedation group and 6.7 in the nonsedation group (P < 0.001).Sedation with propofol increased SBTT but had no effect on CE completion rates, suggesting that CE and colonoscopy with propofol can be performed on the same day (clinical trial registration number: ChiCTR-ONRC-14004866).

Risk factors for surgery in patients with retention of endoscopic capsule

Abstract Objectives: Surgery is still the main means for removing retained endoscopic capsules. This study intended to evaluate risk factors for surgery in patients with capsule retention. Materials and methods: The data of 5348 consecutive capsule endoscopy examinations were retrospectively analyzed. Cox regression analysis was used to evaluate risk factors. Results: Seventy-seven patients (1.4%) had capsule retention. Spontaneous passage occurred in 16 patients, of which 14 were asymptomatic. Successful retrieval by double-balloon enteroscopy (DBE) was achieved in 14 patients, of which 11 did not need surgery during clinical follow-up. A total of 50 patients underwent surgery. The cumulative rates of surgery were 44.2%, 53.2%, 55.8%, 62.3% and 64.9% at 1, 3, 6, 12 and 60 months after capsule retention, respectively. Intestinal obstruction [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.12–3.76; p = .020] and overt small bowel bleeding (HR 2.01, 95%CI 1.08–3.71; p = .027) during capsule retention were independently associated with an increased risk for surgery. Specific treatment for primary disease (HR 0.22, 95%CI 0.07–0.74, p = .014) and successful endoscopic retrieval (HR 0.20, 95%CI 0.06–0.66; p = .008) were independently associated with a decreased risk for surgery. Conclusions: For asymptomatic patients, specific medical treatment for primary disease can be maintained until the capsule spontaneously passes or symptoms appear. For patients with slight abdominal pain, DBE can be performed. For patients with intestinal obstruction or overt small bowel bleeding, early surgical consultation should be considered.