Singh, Dhruv P.

Background: Endoscopic ultrasound–guided rendezvous (EUS-RV) endoscopic retrograde cholangiopancreatography (ERCP) is an alternative to interventional radiology–guided rendezvous ERCP in patients who failed biliary cannulation with conventional ERCP. However, there is significant variation in reported rates of success and adverse events associated with EUS-RV-assisted ERCP. We performed a systematic review and a proportion meta-analysis to reliably assess the effectiveness and safety of the EUS-RV-assisted ERCP. Materials and Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through August 2020) to identify studies reporting EUS-RV-assisted ERCP in patients who failed biliary cannulation with conventional ERCP techniques. Using the random-effects model described by DerSimonian and Laird, we calculated the pooled rates of technical success, clinical success, and adverse events of EUS-RV-assisted ERCP. Results: Twelve studies reporting a total of 342 patients were included in the meta-analysis. The pooled rate of technical success (12 studies reporting a total of 342 patients) was 86.1% [95% confidence interval (CI): 78.4-91.3]. The pooled rate of clinical success (4 studies reporting a total of 94 patients) was 80.8% (95% CI: 64.1-90.8). The pooled rate of overall adverse events (12 studies; 42 events in 342 patients) was 14% (95% CI: 10.5-18.4). Low to moderate heterogeneity was noted in the analyses. Conclusions: EUS-RV-assisted ERCP appears to be effective and safe in patients who failed biliary cannulation with conventional ERCP. Given the risk of adverse events, it should be performed in centers with expertise in therapeutic endoscopic ultrasound.

Abstract Background and study aims With the advent of deep neural networks (DNN) learning, the field of artificial intelligence (AI) is rapidly evolving. Recent randomized controlled trials (RCT) have investigated the influence of integrating AI in colonoscopy and its impact on adenoma detection rates (ADRs) and polyp detection rates (PDRs). We performed a systematic review and meta-analysis to reliably assess if the impact is statistically significant enough to warrant the adoption of AI -assisted colonoscopy (AIAC) in clinical practice. Methods We conducted a comprehensive search of multiple electronic databases and conference proceedings to identify RCTs that compared outcomes between AIAC and conventional colonoscopy (CC). The primary outcome was ADR. The secondary outcomes were PDR and total withdrawal time (WT). Results Six RCTs (comparing AIAC vs CC) with 5058 individuals undergoing average-risk screening colonoscopy were included in the meta-analysis. ADR was significantly higher with AIAC compared to CC (33.7 % versus 22.9 %; odds ratio (OR) 1.76, 95 % confidence interval (CI) 1.55–2.00; I2 = 28 %). Similarly, PDR was significantly higher with AIAC (45.6 % versus 30.6 %; OR 1.90, 95 %CI, 1.68–2.15, I2 = 0 %). The overall WT was higher for AIAC compared to CC (mean difference [MD] 0.46 (0.00–0.92) minutes, I2 = 94 %). Conclusions There is an increase in adenoma and polyp detection with the utilization of AIAC.

PurposeTo develop a two‐stage three‐dimensional (3D) convolutional neural networks (CNNs) for fully automated volumetric segmentation of pancreas on computed tomography (CT) and to further evaluate its performance in the context of intra‐reader and inter‐reader reliability at full dose and reduced radiation dose CTs on a public dataset.MethodsA dataset of 1994 abdomen CT scans (portal venous phase, slice thickness ≤ 3.75‐mm, multiple CT vendors) was curated by two radiologists (R1 and R2) to exclude cases with pancreatic pathology, suboptimal image quality, and image artifacts (n = 77). Remaining 1917 CTs were equally allocated between R1 and R2 for volumetric pancreas segmentation [ground truth (GT)]. This internal dataset was randomly divided into training (n = 1380), validation (n = 248), and test (n = 289) sets for the development of a two‐stage 3D CNN model based on a modified U‐net architecture for automated volumetric pancreas segmentation. Model’s performance for pancreas segmentation and the differences in model‐predicted pancreatic volumes vs GT volumes were compared on the test set. Subsequently, an external dataset from The Cancer Imaging Archive (TCIA) that had CT scans acquired at standard radiation dose and same scans reconstructed at a simulated 25% radiation dose was curated (n = 41). Volumetric pancreas segmentation was done on this TCIA dataset by R1 and R2 independently on the full dose and then at the reduced radiation dose CT images. Intra‐reader and inter‐reader reliability, model’s segmentation performance, and reliability between model‐predicted pancreatic volumes at full vs reduced dose were measured. Finally, model’s performance was tested on the benchmarking National Institute of Health (NIH)‐Pancreas CT (PCT) dataset.ResultsThree‐dimensional CNN had mean (SD) Dice similarity coefficient (DSC): 0.91 (0.03) and average Hausdorff distance of 0.15 (0.09) mm on the test set. Model’s performance was equivalent between males and females (P = 0.08) and across different CT slice thicknesses (P > 0.05) based on noninferiority statistical testing. There was no difference in model‐predicted and GT pancreatic volumes [mean predicted volume 99 cc (31cc); GT volume 101 cc (33 cc), P = 0.33]. Mean pancreatic volume difference was −2.7 cc (percent difference: −2.4% of GT volume) with excellent correlation between model‐predicted and GT volumes [concordance correlation coefficient (CCC)=0.97]. In the external TCIA dataset, the model had higher reliability than R1 and R2 on full vs reduced dose CT scans [model mean (SD) DSC: 0.96 (0.02), CCC = 0.995 vs R1 DSC: 0.83 (0.07), CCC = 0.89, and R2 DSC:0.87 (0.04), CCC = 0.97]. The DSC and volume concordance correlations for R1 vs R2 (inter‐reader reliability) were 0.85 (0.07), CCC = 0.90 at full dose and 0.83 (0.07), CCC = 0.96 at reduced dose datasets. There was good reliability between model and R1 at both full and reduced dose CT [full dose: DSC: 0.81 (0.07), CCC = 0.83 and reduced dose DSC:0.81 (0.08), CCC = 0.87]. Likewise, there was good reliability between model and R2 at both full and reduced dose CT [full dose: DSC: 0.84 (0.05), CCC = 0.89 and reduced dose DSC:0.83(0.06), CCC = 0.89]. There was no difference in model‐predicted and GT pancreatic volume in TCIA dataset (mean predicted volume 96 cc (33); GT pancreatic volume 89 cc (30), p = 0.31). Model had mean (SD) DSC: 0.89 (0.04) (minimum–maximum DSC: 0.79 −0.96) on the NIH‐PCT dataset.ConclusionA 3D CNN developed on the largest dataset of CTs is accurate for fully automated volumetric pancreas segmentation and is generalizable across a wide range of CT slice thicknesses, radiation dose, and patient gender. This 3D CNN offers a scalable tool to leverage biomarkers from pancreas morphometrics and radiomics for pancreatic diseases including for early pancreatic cancer detection.

AbstractBackground Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events.Methods We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone.Results 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 – 83.6) and 64.8 % (95 %CI 53.1 – 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 – 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 – 92.2) and 72.5 % (95 %CI 52.3 – 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 – 14.5). Substantial heterogeneity was noted.Conclusions OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.

INTRODUCTION: In patients with acute cholecystitis who were deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for decompression of the gallbladder. There are several limitations associated with PC. Endoscopic gallbladder drainage [Endoscopic trans-papillary gallbladder drainage (ET-GBD) via ERCP and EUS-guided gallbladder drainage (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the outcomes between the two endoscopic techniques (EUS-GBD vs ET-GBD). METHODS: We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in management of acute cholecystitis in high risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. RESULTS: Five comparative studies with a total of 861 patients; were included in the analysis. The pooled OR for technical success of EUS-GBD in comparison to ET-GBD was 5.22 (95% CI: 2.03-13.44; P = 0.01; I 2 = 20%). The pooled OR for clinical success (EUS-GBD vs ET-GBD) in intention-to-treat analysis was 4.16 (95% CI: 2.00-8.66; P = 0.001; I 2 = 19%) and per-protocol analysis was 1.81 (95% CI: 0.80-4.09; P = 0.15; I 2 =0%). The pooled OR for overall acute adverse events (EUS-GBD vs ET-GBD) was 1.32 (95% CI: 0.78 -2.25; P = 0.31, I 2 = 0%). The pooled OR for perforation and pancreatitis (EUS-GBD vs ETGBD) were 1.98 (95% CI: 0.32-12.29) and 0.19 (95% CI: 0.03-0.99) respectively. The pooled OR for recurrent cholecystitis (EUS-GBD vs ETGBD) was 0.33 (95% CI: 0.13-0.82). There was minimal heterogeneity in the analysis. CONCLUSION: EUS-GBD is associated with higher rate of technical and clinical success compared to ET-GBD. While the rate of overall acute adverse events are statistically similar between the two techniques, EUS-GBD is associated with lower rate of recurrent cholecystitis. In centers with expertise in EUS, EUS-GBD could be considered as first-line treatment in carefully selected patients.

INTRODUCTION: Surgical gastroenterostomy has been the traditional approach to manage malignant gastric outlet obstruction (GOO). With advances in Endoscopic Ultrasound (EUS) technology and availability of dedicated devices and stents for EUS scopes, EUS guided gastroenterostomy (GE) is emerging as an alternative to surgical gastroenterostomy. Recently studies have been published comparing the outcomes between these two approaches. We performed a systematic review and meta-analysis of studies that compare the outcomes between the two approaches (EUS-GE vs Surgical GE). METHODS: We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GE vs surgical GE in management of malignant gastric outlet obstruction. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GE and surgical GE groups were calculated. RESULTS: Three comparative studies with a total of 171 patients; were included in the analysis. The pooled OR for technical success of EUS-GE in comparison to surgical GE was 0.16 (95% CI: 0.03-0.86; P = 0.033; I 2 = 2%). The pooled OR for clinical success (EUS-GE vs surgical GE) was 0.98 (95% CI: 0.13-7.48; P = 0.984; I 2 = 25%) The pooled OR for overall adverse events (EUS-GE vs surgical GE) was 0.35 (95% CI: 0.15-0.81; P = 0.014, I 2 = 0%). There was minimal heterogeneity in the analysis. CONCLUSION: While EUS-GE is associated with similar rates of clinical success compared to surgical GE, the rate of overall adverse events is statistically lower. Hence in centers with expertise in EUS, EUS-GE could be considered as an effective alternate option.

INTRODUCTION: Endoscopic ultrasound (EUS) guided gastroenterostomy (GE) is emerging as an alternative to enteral stenting and surgical GE for management of malignant gastric outlet obstruction (GOO). With advances in EUS technology and availability of dedicated devices/stents for EUS scopes, the use of EUS-GE is expected to increase in the future. We performed a systematic review and meta-analysis to estimate the success rate and adverse events associated with EUS-GE. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through May 2019) to identify studies that reported success rate and adverse events of EUS-GE. The primary outcome was to estimate the pooled rates of technical and clinical success of EUS-GE. The secondary outcome was to estimate the rate of adverse events. RESULTS: 9 studies with a total of 268 patients were included. The pooled rate of technical success of EUS-GE was 91.7 % (95% CI 87.5 – 94.5; I2 = 0). The pooled rate of clinical success of EUS-GJ was 87.8% (95% CI 83.1 – 91.3; I 2 = 0). The pooled rate of overall adverse events was 12.6% (95% CI 9.0- 17.6; I 2 = 0). The pooled rate of individual adverse events – perforation, bleeding, peritonitis and stent migration / misdeployment were 2% (95% CI 0.7 – 5.1), 3.2% (95% CI 1.5 – 6.5), 2.6% (95% CI 1.1-6.1) and 8.9 % (95% CI 4.3-17.5) respectively.The rate of surgical intervention for adverse events was 2%. CONCLUSION: While the rates of technical success (92%) and clinical success (88%) of EUS-GJ is promising, the risk of adverse events is considerable at 12.6%, with stent misdeployment (9%) being the most common adverse event. Hence, EUS-GJ should be performed at tertiary referral centers in a multidisciplinary (surgery, oncology, gastroenterology) team-based approach.

INTRODUCTION: Esophageal cancer accounts for 1% of cancers diagnosed in the United States and the seventh most common cause of cancer-related mortality among men in the United States, with a 5-year survival rate of 19%. With an estimated $1.5 billion in direct medical costs in 2010, we look at ED utilization by this group of patients and analyze the economic burden and trends in ED visits and inpatient admissions over a 9-year period METHODS: The Nationwide Emergency Department Sample (NEDS; 2006-2014) was interrogated to identify patients with a primary diagnosis of esophageal cancer (ICD-9 CM code). The yearly incidence of ED visits, rates of hospitalization, length of stay (LOS), and total charges associated with ED or subsequent inpatient stays were assessed. As secondary analysis, survey logistic regression model was used to determine predictors of hospitalization. RESULTS: A total of 46,431 esophageal cancer-related ED visits were identified during this time period. Overall, early readmission visits increased overall from 6,295 in 2006 to a peak of 6,837 in 2014. The mean ED charges per visit, adjusted to inflation increased significantly from $1,401 in 2006 to $3,168 in 2014, while the mean total charges incurred by patients who were admitted to the hospital also increased from $41,009 in 2006 to $61,809 in 2014. Hospitalization rates decreased from 83.5% in 2006 to 78.8% in 2014 but in-hospital deaths decreased from 11.4% in 2006 to 8.7% in 2014. The average LOS in the hospitals decreased from 7.8 to 7.2 days. CONCLUSION: Increasing ED visits and charges associated with esophageal cancer are concerning. While hospitalization rates are slightly decreased during this 9-year period, there is an alarming uptrend in mortality rates which needs to be explored further. The results of our study suggest that further exploring factors that are associated with the recent upsurge in mortality may lead to the development of interventions that will significantly reduce in-hospital deaths.