Beran, Azizullah

Abstract We aim to compare the benefits, harms, and costs of multiple plastic stents (MPS) versus covered self-expandable metallic stents (CSEMS) in the treatment of benign biliary strictures (BBS). A comprehensive database search through June 6, 2024 identified randomized controlled trials (RCT) involving adult patients with BBS comparing MPS to CSEMS in terms of stricture resolution, recurrence, technical success, number of required procedures and stents, treatment duration, all-cause mortality, adverse events, and stent migration. We utilized the Cochrane Risk of Bias (RoB) tool2 for study quality assessment. Meta-analysis following the random effects model was performed. After screening 365 references, we included 7 RCTs (high RoB) involving 594 patients. Most reported stricture etiology is chronic pancreatitis (52.4%), followed by orthotopic liver transplant (40.5%). Compared with MPS, CSEMS achieved similar efficacy and safety. However, CSEMS required fewer procedures (mean difference [MD]: −1.84 [−2.56 to −1.11]; I2 = 76%) and stents (MD: −6.04 [−9.55 to −2.52]; I2 = 93%), amounting for shorter duration of treatment (MD: −119.02 days [−137.41 to −100.62]; I2 = 96%) and savings in costs between 41 and 57% with absolute savings of 4,019$ to 9,192$ favoring CSEMS. All outcomes had a low to very low certainty of evidence (CoE), except for technical success and stricture resolution (moderate CoE). Our analysis suggests that CSEMSs are comparable to MPSs in terms of efficacy and safety. However, it shows that CSEMSs are more cost-effective. Sample size calculations from our analyses can guide the design of future studies to validate the safety profiles and determine the feasibility of the two modalities.

ABSTRACTBackgroundAchalasia is associated with an increased risk of esophageal cancer; though reported incidence rates vary widely (0.4% to 9.2%) due to differences in demographics, follow‐up duration, and diagnostic methods. This study evaluates the risk of esophageal cancer and Barrett's esophagus (BE) in achalasia using a large national database and a propensity‐matched control cohort.MethodsAchalasia patients were identified utilizing the TriNetX database based on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes for diagnostic procedures and lower esophageal sphincter (LES) directed therapies, including Heller myotomy, peroral endoscopic myotomy, and pneumatic dilation. A matched control group of celiac disease patients was used. A 1‐year lead time was applied to exclude secondary malignant achalasia. Outcomes included the incidence of esophageal cancer and BE, with subgroup analysis in patients following therapy.ResultsAmong 7863 achalasia patients (mean age 58.0, 51.9% female), the esophageal cancer risk was significantly higher than control (risk ratio 2.87, 95% CI: 1.56–5.27, p < 0.001). The absolute risk was low, with 40 cases (0.51%) over a mean follow‐up of 3.18 years. BE risk was also higher in achalasia (risk ratio 1.54, 95% CI: 1.24–1.90, p < 0.001), with 220 cases (2.80%). Subgroup analysis revealed no significant difference in BE risk between POEM and Heller myotomy (risk ratio 1.0, 95% CI: 0.42–2.40, p > 0.99).DiscussionThe elevated cancer risk in achalasia over a short follow‐up period warrants reconsideration of current endoscopic surveillance guidelines, despite the low absolute risk of esophageal cancer and BE.

Abstract Artificial intelligence (AI) and mucosal exposure devices like Endocuff have independently improved the adenoma detection rate (ADR) during colonoscopy. This meta-analysis evaluated the combined effect of Endocuff and AI versus AI alone on colorectal neoplasia detection rates. We searched PubMed, Embase, and Web of Science for randomized controlled trials (RCTs) comparing the impact of Endocuff+AI versus AI alone on colorectal neoplasia detection. Primary outcome was ADR; secondary outcomes included advanced adenoma detection rate (AADR), sessile serrated lesion detection rate (SSLDR), cecal intubation time, and withdrawal time. Pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Three RCTs with 2404 subjects were included (n = 1198 Endocuff+AI vs. n = 1206 AI alone). ADR was significantly higher in the Endocuff+AI group than in the AI alone group (54% vs. 48%, respectively) (RR 1.12, 95% CI 1.03–1.21, P = 0.01, I2 = 0%). There was a trend toward higher AADR (12.3% vs. 10%, RR 1.23, 95% CI 0.96–1.59, P = 0.10, I2 = 17%) and SSLDR (17.6% vs. 15.5%, RR 1.16, 95% CI 0.96–1.40, P = 0.13, I2 = 0%) in the Endocuff+AI group compared with the AI alone group, but it did not reach statistical significance. Both cecal intubation time (MD -0.61 minutes; 95% CI -1.54–0.33; P = 0.20; I2 = 87%) and withdrawal time (MD -0.42 minutes; 95% CI -1.01–0.17; P = 0.17, I2 = 60%) were similar between the two groups. Endocuff combined with AI was superior to AI alone in improving the adenoma detection rate without increasing intubation or withdrawal times.

Background and aims Percutaneous endoscopic gastrostomy (PEG) is an essential procedure for patients who require long-term enteral nutrition but are unable to eat orally. However, it carries a risk of bleeding, particularly in patients on anticoagulation or dual antiplatelet therapy (DAPT). This study aimed to assess the bleeding risk associated with continuing anticoagulation or DAPT during PEG placement. Methods Using the TriNetX US Collaborative Network Database, we analyzed four cohorts: patients on anticoagulants, patients not on anticoagulants, patients on DAPT, and patients on aspirin (ASP), focusing on gastrostomy-related bleeding within 7 and 30 days, along with secondary outcomes such as mortality and the need for blood transfusion or endoscopic reintervention. Results Our analysis showed no statistically significant difference in the 7-day bleeding risk between the anticoagulant and no anticoagulant groups. However, a higher 30-day bleeding risk was observed in the anticoagulant group (0.9 vs. 0.4%, P = 0.007). There was no significant difference in the incidence of severe bleeding events requiring endoscopic intervention or blood transfusion. In addition, the difference in the bleeding risk between the DAPT and ASP groups was not statistically significant within 7 and 30 days. Conclusion These findings suggest that while anticoagulant use increases the risk of minor post-PEG bleeding, it does not lead to a higher incidence of severe bleeding. Additionally, the continuation of DAPT was not associated with statistically significant increase in bleeding risk. This study provides valuable insights into the management of antithrombotic therapy in patients undergoing PEG.

Abstract Background Studies evaluating the risk of post-polypectomy bleeding (PPB) after colorectal endoscopic mucosal resection (EMR) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are limited. Methods This retrospective cohort study utilized the U.S. Collaborative Network to assess the risk of PPB after colorectal EMR in patients with CKD compared to controls. Using one-to-one propensity score matching (PSM), the primary outcome measured was PPB within 30 days after colorectal EMR. The PPB risk was further stratified by CKD severity: non-advanced CKD and advanced CKD. Results After PSM, each cohort included 7,460 patients. Overall, CKD was associated with increased risk of PPB following colorectal EMR (5.5% vs. 4%, odds ratio [OR] 1.38, 95% confidence interval [CI] 1.19–1.61, p < 0.001). The PPB risk was significantly higher in patients with advanced CKD (8.1% vs, 4.6%, OR 1.83, 95% CI 1.43–2.34, p < 0.001), while those with non-advanced CKD showed modest increase in risk of PPB (4.7% vs. 3.9%, OR 1.21, 95% CI 1.001–1.46, p = 0.049). Conclusion Patients with CKD had higher risk of PPB than patients without CKD, but absolute risk remained low. The PPB risk was notably increased in patients with advanced CKD. Optimizing patients with CKD, especially advanced CKD, before colorectal EMR and monitoring for post-procedure bleeding remains important.

INTRODUCTION: The impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on colonoscopy bowel preparation is unclear. METHODS: We searched multiple databases for studies comparing bowel preparation quality between GLP-1RA users and the control group. Using a random-effects model, we calculated pooled odds ratios and mean differences with 95% confidence intervals (CIs). Inadequate bowel preparation (IBP) rate was the primary outcome, and Boston Bowel Preparation Scale mean score was the secondary outcome. RESULTS: Five studies with 10,833 patients (n = 5,434 GLP-1RAs vs n = 5,399 control) were included. The IBP rate was higher in the GLP-1RAs group compared with the control group (odds ratios 2.10, 95% CI 1.41–3.13, P = 0.0003). Furthermore, the mean Boston Bowel Preparation Scale score was lower in the GLP1-RAs group compared with the control group (mean differences −0.34; 95% CI −0.51, −0.17; P = 0.0001). DISCUSSION: Our findings suggest that using GLP-1RA increases the risk of IBP.

AbstractCholecystectomy is the standard treatment for acute cholecystitis, but it may not be suitable for all patients. For those who cannot undergo surgery, a percutaneous cholecystostomy tube (PCT) and ERCP-guided transpapillary gallbladder drainage are viable options. We aimed to perform a nationwide study to assess 30-day readmission rates, adverse events (AEs), and mortality rates in these two cohorts.We conducted a nationwide cohort study using data from the Nationwide Readmissions Database (NRD) from 2016 to 2019. We identified patients with acute cholecystitis during the index admission who underwent either PCT or ERCP-guided gallbladder drainage. Propensity score matching along with multivariable regression was used to compare cohorts.During the study period, 3,592 patients (average age 63.0 years) underwent endoscopic drainage, whereas 80,372 patients (average 70.8 years) underwent Interventional Radiology drainage. Utilizing multivariate Cox regression analysis, compared with ERCP, PCT had a higher risk for 30-day readmission (adjusted hazard ratio [aHR] 1.47; 95% confidence interval [CI] 1.27 to 1.71; P < 0.001). The PCT group had a significantly higher rate of readmission for acute cholecystitis compared with the ERCP group (2.72% vs 0.86%; P < 0.005). Cox proportional hazard ratio showed a 3.41-fold increased risk (95% CI 1.99 to 5.84) for readmission in the PCT group. ERCP was consistently associated with lower rates of post-procedural AEs compared with PCT including acute hypoxemic respiratory failure (P < 0.001), acute renal failure (P < 0.001), shock (P < 0.001), and need for blood transfusions (P < 0.001).Our nationwide analysis revealed that ERCP-guided gallbladder drainage should be the preferred approach for managing acute cholecystitis when unfit for surgery.

INTRODUCTION: Data on the risk of post-polypectomy bleeding after endoscopic mucosal resection (EMR) in patients with cirrhosis are limited. METHODS: This retrospective cohort study used the US Collaborative Network to assess post-polypectomy bleeding risk after colorectal EMR in patients with cirrhosis compared with controls. Using one-to-one propensity score matching, the primary outcome measured was bleeding within 30 days post-EMR. The bleeding risk was further stratified by cirrhosis severity (compensated and decompensated). RESULTS: After propensity score matching, each cohort included 2,381 patients. Patients with cirrhosis had a higher risk of post-polypectomy bleeding (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.05–1.82, P = 0.02). However, endoscopic reinterventions for hemostasis were similar between cirrhosis and control cohorts (OR 1.20, 95% CI 0.71–2.05, P = 0.50). The post-polypectomy bleeding risk was significantly higher in patients with decompensated cirrhosis (OR 1.65, 95% CI 1.12–2.42, P = 0.01), while those with compensated cirrhosis showed no increased risk of post-polypectomy bleeding (OR 1.15, 95% CI 0.85–1.54, P = 0.37). DISCUSSION: The post-polypectomy bleeding risk was higher in patients with decompensated cirrhosis, while the bleeding risk was not increased in those with compensated disease. Optimizing patients with cirrhosis, especially with decompensated disease, before colorectal EMR and monitoring for post-procedure bleeding remain important. A conservative, supportive approach to managing bleeding in patients with cirrhosis may be as effective as in those without cirrhosis.