Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding:A systematic review and metaanalysis

AIM To compare the diagnostic accuracy of video capsule endoscopy(VCE) and double-balloon enteroscopy(DBE) in cases of obscure gastrointestinal bleeding(OGIB) of vascular origin.METHODS MEDLINE(via PubMed), LILACS(via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables(sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software.RESULTS In the per-patient analysis, 17 studies(1477 lesions) were included. We identified3150 exams(1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864(58.5%) were diagnosed by VCE, and 613(41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84%(95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was92%(95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29(95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20(95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to90%.CONCLUSION The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Pancreatitis after endoscopic retrograde cholangiopancreatography:A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP)is a feared and potentially fatal complication that can be as high as up to 30%in high-risk patients.Pre-examination measures,during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events.Several studies have debated on the subject,however,numerous topics remain controversial,such as the effectiveness of prophylactic medications and the amylase dosage time.This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

A gastrointestinal(GI) transmural defect is defined as total rupture of the GI wall,and these defects can be divided into three categories: perforations,leaks,and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently,several novel endoscopic techniques have been developed,and endoscopy has become a firstline approach for therapy of these conditions. The use of endoscopic vacuum therapy(EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms,including macrodeformation,microdeformation,changes in perfusion,exudate control,and bacterial clearance,which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract,small bowel,biliopancreatic regions,and lower GI tract,with variable success rates and a satisfactory safety profile. In this article,we review and discuss the mechanism of action,materials,techniques,efficacy,and safety of EVT in the management of patients with GI transmural defects.

Propofol vs traditional sedatives for sedation in endoscopy:A systematic review and meta-analysis

BACKGROUND Propofol is commonly used for sedation during endoscopic procedures.Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved postprocedure recovery times for patients.However,Propofol requires administration by trained healthcare providers,has a narrow therapeutic index,lacks an antidote and increases risks of cardio-pulmonary complications.AIM To compare,through a systematic review of the literature and meta-analysis,sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.METHODS A literature search was performed using MEDLINE,Scopus,EMBASE,the Cochrane Library,Scopus,LILACS,BVS,Cochrane Central Register of Controlled Trials,and The Cumulative Index to Nursing and Allied Health Literature databases.The last search in the literature was performed on March,2019 with no restriction regarding the idiom or the year of publication.Only randomized clinical trials with full texts published were included.We divided sedation therapies to the following groups:(1)Propofol versus benzodiazepines and/or opiate sedatives;(2)Propofol versus Propofol with benzodiazepine and/or opioids;and(3)Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid.The following outcomes were addressed:Adverse events,patient satisfaction with type of sedation,endoscopists satisfaction with sedation administered,dose of propofol administered and time to recovery post procedure.Meta-analysis was performed using RevMan5 software version 5.39.RESULTS A total of 23 clinical trials were included(n=3854)from the initial search of 6410 articles.For Group I(Propofol vs benzodiazepine and/or opioids):The incidence of bradycardia was not statistically different between both sedation arms(RD:-0.01,95%CI:-0.03–+0.01,I2:22%).In 10 studies,the incidence of hypotension was not statistically difference between sedation arms(RD:0.01,95%CI:-0.02–+0.04,I2:0%).Oxygen desaturation was higher in the propofol group but not statistically different between groups(RD:-0.03,95%CI:-0.06–+0.00,I2:25%).Patients were more satisfied with their sedation in the benzodiazepine+opioid group compared to those with monotherapy propofol sedation(MD:+0.89,95%CI:+0.62–+1.17,I2:39%).The recovery time after the procedure showed high heterogeneity even after outlier withdrawal,there was no statistical difference between both arms(MD:-15.15,95%CI:-31.85–+1.56,I2:99%).For Group II(Propofol vs propofol with benzodiazepine and/or opioids):Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioidassociated(RD:-0.08,95%CI:-0.13–-0.02,I2:59%).There was no statistical difference in the incidence of bradycardia(RD:-0.00,95%CI:-0.08–+0.08,I2:85%),desaturation(RD:-0.00,95%CI:-0.03–+0.02,I2:44%)or recovery time(MD:-2.04,95%CI:-6.96–+2.88,I2:97%)between sedation arms.The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity.(MD:70.36,95%CI:+53.11–+87.60,I2:61%).For Group III(Propofol with benzodiazepine and opioid vs benzodiazepine and opioid):Bradycardia and hypotension was not statistically significant between groups(RD:-0.00,95%CI:-0.002–+0.02,I2:3%;RD:0.04,95%CI:-0.05–+0.13,I2:77%).Desaturation was evaluated in two articles and was higher in the propofol+benzodiazepine+opioid group,but with high heterogeneity(RD:0.15,95%CI:0.08–+0.22,I2:95%).CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections-review and new proposed classification

Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated.Within the last decade,endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage.Proper understanding of anatomic landmarks,including assessment of the main pancreatic duct and any associated lesions–such as disruptions and strictures-are key to achieving clinical success,reducing the need for reintervention or recurrence,especially in cases with suspected disconnected pancreatic duct syndrome.Additionally,proper review of imaging and anatomic landmarks,including collection location,are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents.Pancreatography to adequately assess the main pancreatic duct may be performed by two methods:Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopancreatography.Despite the critical need to understand anatomy via pancrea tography and assess the main pancreatic duct,a standardized approach or uniform assessment strategy has not been described in the literature.Therefore,the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.

Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis:A systematic review and meta-analysis of randomized controlled trials

BACKGROUND Patients with cirrhosis frequently require sedation for elective endoscopic procedures.Several sedation protocols are available,but choosing an appropriate sedative in patients with cirrhosis is challenging.AIM To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.METHODS This systematic review and meta-analysis was conducted using the PRISMA guidelines.Electronic searches were performed using MEDLINE,EMBASE,Central Cochrane,LILACS databases.Only randomized control trials(RCTs)were included.The outcomes studied were procedure time,recovery time,discharge time,and adverse events(bradycardia,hypotension,and hypoxemia).The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials(RoB-2).Quality of evidence was evaluated by GRADEpro.The meta-analysis was performed using Review Manager.RESULTS The search yielded 3,576 records.Out of these,8 RCTs with a total of 596 patients(302 in the propofol group and 294 in the midazolam group)were included for the final analysis.Procedure time was similar between midazolam and propofol groups(MD:0.25,95%CI:-0.64 to 1.13,P=0.59).Recovery time(MD:-8.19,95%CI:-10.59 to-5.79,P<0.00001).and discharge time were significantly less in the propofol group(MD:-12.98,95%CI:-18.46 to-7.50,P<0.00001).Adverse events were similar in both groups(RD:0.02,95%CI:0-0.04,P=0.58).Moreover,no significant difference was found for bradycardia(RD:0.03,95%CI:-0.01 to 0.07,P=0.16),hypotension(RD:0.03,95%CI:-0.01 to 0.07,P=0.17),and hypoxemia(RD:0.00,95%CI:-0.04 to 0.04,P=0.93).Five studies had low risk of bias,two demonstrated some concerns,and one presented high risk.The quality of the evidence was very low for procedure time,recovery time,and adverse events;while low for discharge time.CONCLUSION This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events.These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.

Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases

BACKGROUND Gastrointestinal stromal tumors(GISTs)originate from interstitial cells of Cajal.GISTs can occur anywhere along the gastrointestinal tract.Large lesions have traditionally been removed surgically.However,with recent innovations in advanced endoscopy,GISTs located within the stomach are now removed endoscopically.We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs.CASE SUMMARY We present a series of three patients who were diagnosed with a gastric GIST.All patients underwent full-thickness endoscopic resection.In all cases,for closure of the surgical bed,conventional endoscopic techniques including hemoclips,endoloop and suturing were unsuccessful.We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices.All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast.CONCLUSION The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.

Gallbladder perforation due to endoscopic sleeve gastroplasty: A case report and review of literature

BACKGROUND The healthcare impact of obesity is enormous,and there have been calls for new approaches to containing the epidemic worldwide.Minimally invasive procedures have become more popular,with one of the most widely used being endoscopic sleeve gastroplasty(ESG).Although major adverse events after ESG are rare,some can cause considerable mortality.To our knowledge,there has been no previous report of biliary ascites after ESG.CASE SUMMARY A 48-year-old female with obesity refractory to lifestyle changes and prior gastric balloon placement underwent uncomplicated ESG and was discharged on the following day.On postoperative day 3,she developed abdominal pain,which led to an emergency department visit the following day.She was readmitted to the hospital,with poor general health status and signs of peritoneal irritation.Computed tomography imaging showed fluid in the abdominal cavity.Laparoscopy revealed biliary ascites and showed that the gallbladder was sutured to the gastric wall.The patient underwent cholecystectomy and lavage of the abdominal cavity and was admitted to the intensive care unit postoperatively.After 7 d of antibiotic therapy and 20 d of hospitalization,she was discharged.Fortunately,6 mo later,she presented in excellent general condition and with a 20.2%weight loss.CONCLUSION ESG is a safe procedure.However,adverse events can still occur,and precautions should be taken by the endoscopist.In general,patient position,depth of tissue acquisition,location of stitch placement,and endoscopist experience are all important factors to consider to mitigate procedural risk.

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND Roux-en-Y gastric bypass(RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis(GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation(APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.CASE SUMMARY A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA.Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel.Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.CONCLUSION APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions:A multi-center analysis

BACKGROUND While endoscopic ultrasound(EUS)-guided fine needle aspiration(FNA)is considered a preferred technique for tissue sampling for solid lesions,fine needle biopsy(FNB)has recently been developed.AIM To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions.METHODS A retrospective,multi-center study of EUS-guided tissue sampling using FNA vs FNB needles.Measured outcomes included diagnostic test characteristics(i.e.,sensitivity,specificity,accuracy),use of rapid on-site evaluation(ROSE),and adverse events.Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE.A multivariable logistic regression was also performed.RESULTS A total of 1168 patients with solid lesions(n=468 FNA;n=700 FNB)underwent EUS-guided sampling.Mean age was 65.02±12.13 years.Overall,sensitivity,specificity and accuracy were superior for FNB vs FNA(84.70%vs 74.53%;99.29%vs 96.62%;and 87.62%vs 81.55%,respectively;P<0.001).On subgroup analyses,sensitivity,specificity,and accuracy of FNB alone were similar to FNA+ROSE[(81.66%vs 86.45%;P=0.142),(100%vs 100%;P=1.00)and(88.40%vs 85.43%;P=0.320].There were no difference in diagnostic yield of FNB alone vs FNB+ROSE(P>0.05).Multivariate analysis showed no significant predictor for better accuracy.On subgroup analyses,FNB was superior to FNA for non-pancreatic lesions;however,there was no difference between the techniques among pancreatic lesions.One adverse event was reported in each group.CONCLUSION FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA+ROSE in the diagnosis of non-pancreatic solid lesions.Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction——stent-in-stent or side-by-side?A systematic review and meta-analysis

BACKGROUND Biliary drainage,either by the stent-in-stent(SIS)or side-by-side(SBS)technique,is often required when treating a malignant hilar biliary obstruction(MHBO).Both methods differ from each other and have distinct advantages.AIM To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.METHODS A comprehensive search of multiple electronic databases(MEDLINE,Embase,LILACS,BIREME,Cochrane)was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language,since there was at least an abstract in English.The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography.Outcomes analyzed included technical and clinical success,early and late adverse events(AEs),stent patency,reintervention,and procedure-related mortality.RESULTS Four cohort studies and one randomized controlled trial evaluating a total of 250 patients(127 in the SIS group and 123 in the SBS group)were included in this study.There were no statistically significant differences between the two groups concerning the evaluated outcomes,except for stent patency,which was higher in the SIS compared with the SBS technique[mean difference(d)=33.31;95%confidence interval:9.73 to 56.90,I2=45%,P=0.006].CONCLUSION The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO.Both techniques are equivalent in terms of technical success,clinical success,rates of both early and late AEs,reintervention,and procedure-related mortality.

Acute abdominal obstruction:Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017,colorectal cancer(CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018.Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction(MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990 s, selfexpanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

Fecal microbiota transplantation in patients with metabolic syndrome and obesity:A randomized controlled trial

BACKGROUND Metabolic syndrome is a multifactorial disease,and the gut microbiota may play a role in its pathogenesis.Obesity,especially abdominal obesity,is associated with insulin resistance,often increasing the risk of type two diabetes mellitus,vascular endothelial dysfunction,an abnormal lipid profile,hypertension,and vascular inflammation,all of which promote the development of atherosclerotic cardiovascular disease.AIM To evaluate the outcomes of fecal microbiota transplantation(FMT)in patients with metabolic syndrome.METHODS This was a randomized,single-blind placebo-controlled trial comparing FMT and a sham procedure in patients with metabolic syndrome.We selected 32 female patients,who were divided into eight groups of four patients each.All of the patients were submitted to upper gastrointestinal endoscopy.In each group,two patients were randomly allocated to undergo FMT,and the other two patients received saline infusion.The patients were followed for one year after the procedures,during which time anthropometric,bioimpedance,and biochemical data were collected.The patients also had periodic consultations with a nutritionist and an endocrinologist.The primary end point was a change in the gut microbiota.RESULTS There was evidence of a postprocedural change in microbiota composition in the patients who underwent FMT in relation to that observed in those who underwent the sham procedure.However,we found no difference between the two groups in terms of the clinical parameters evaluated.CONCLUSION There were no significant differences in biochemical or anthropometric parameters,between the two groups evaluated.Nevertheless,there were significant postprocedural differences in the microbiota composition between the placebo group.To date,clinical outcomes related to FMT remain uncertain.

Sodium picosulphate or polyethylene glycol before elective colonoscopy in outpatients?A systematic review and meta-analysis

AIM To determine the best option for bowel preparation [sodium picosulphate or polyethylene glycol(PEG)] for elective colonoscopy in adult outpatients.METHODS A systematic review of the literature following the PRISMA guidelines was performed using Medline, Scopus, EMBASE, Central, Cinahl and Lilacs. No restrictions were placed for country, year of publication or language. The last search in the literature was performed on November 20th, 2017. Only randomized clinical trials with full texts published were included. The subjects included were adult outpatients who underwent bowel cleansing for elective colonoscopy. The included studies compared sodium picosulphate with magnesium citrate(SPMC)and PEG for bowel preparation. Exclusion criteria were the inclusion of inpatients or groups with specific conditions, failure to mention patient status(outpatient or inpatient) or dietary restrictions, and permission to have unrestricted diet on the day prior to the exam. Primary outcomes were bowel cleaning success and/or tolerability of colon preparation. Secondary outcomes were adverse events, polyp and adenoma detection rates. Data on intention-totreat were extracted by two independent authors and risk of bias assessed through the Jadad scale. Funnel plots, Egger's test, Higgins' test(I2) and sensitivity analyses were used to assess reporting bias and heterogeneity. The meta-analysis was performed by computing risk difference(RD) using MantelHaenszel(MH) method with fixed-effects(FE) and random-effects(RE) models.Review Manager 5(RevMan 5) version 6.1(The Cochrane Collaboration) was the software chosen to perform the meta-analysis.RESULTS662 records were identified but only 16 trials with 6200 subjects were included for the meta-analysis. High heterogeneity among studies was found and sensitivity analysis was needed and performed to interpret data. In the pooled analysis,SPMC was better for bowel cleaning [MH FE, RD 0.03, IC(0.01, 0.05), P = 0.003, I2= 33%, NNT 34], for tolerability [MH RE, RD 0.08, IC(0.03, 0.13), P = 0.002, I2 =88%, NNT 13] and for adverse events [MH RE, RD 0.13, IC(0.05, 0.22), P = 0.002,I2 = 88%, NNT 7]. There was no difference in regard to polyp and adenoma detection rates. Additional analyses were made by subgroups(type of regimen,volume of PEG solution and dietary recommendations). SPMC demonstrated better tolerability levels when compared to PEG in the following subgroups:"day-before preparation" [MH FE, RD 0.17, IC(0.13, 0.21), P < 0.0001, I2 = 0%,NNT 6], "preparation in accordance with time interval for colonoscopy" [MH RE,RD 0.08, IC(0.01, 0.15), P = 0.02, I2 = 54%, NNT 13], when compared to "highvolume PEG solutions" [MH RE, RD 0.08, IC(0.01, 0.14), I2 = 89%, P = 0.02, NNT13] and in the subgroup "liquid diet on day before" [MH RE, RD 0.14, IC(0.06,0.22), P = 0.0006, I2 = 81%, NNT 8]. SPMC was also found to cause fewer adverse events than PEG in the "high-volume PEG solutions" [MH RE, RD-0.18,IC(-0.30,-0.07), P = 0.002, I2 = 79%, NNT 6] and PEG in the "low-residue diet"subgroup [MH RE, RD-0.17, IC(-0.27, 0.07), P = 0.0008, I2 = 86%, NNT 6].CONCLUSION SPMC seems to be better than PEG for bowel preparation, with a similar bowel cleaning success rate, better tolerability and lower prevalence of adverse events.

Gastrointestinal symptoms in patients with COVID-19: Is there a relationship with mortality and new variations of SARS-CoV-2?

Coronavirus disease 2019(COVID-19)is caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2).Although,respiratory symptoms are typical the digestive system is also a susceptible target with gastrointestinal symptoms present even in the absence of respiratory symptoms.The gastrointestinal symptoms of COVID-19 include diarrhea,abdominal pain,anorexia,and nausea among other symptoms.Some questions that remain to be answered include:Do patients with gastrointestinal symptoms have a higher mortality?SARS-CoV-2 variants are already a global reality:Do these variants present with a greater prevalence of gastrointestinal symptoms?Do patients with these symptoms warrant more intensive care unit care?

Status of bariatric endoscopy–what does the surgeon need to know? A review

BACKGROUND Obesity is a chronic and multifactorial disease with a variety of potential treatment options available.Currently,there are several multidisciplinary therapeutic options for its management,including conservative,endoscopic,and surgical treatment.AIM To clarify indications,technical aspects,and outcomes of bariatric endoscopy.METHODS Narrative review of current literature based on electronic databases including MEDLINE(PubMed),Cochrane Library,and SciELO.RESULTS Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications.Various devices act upon different mechanisms of action,which may be individualized to each patient.Despite favorable results for the endoscopic treatment of obesity,prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies.Regarding the management of bariatric surgery complications,endoscopic therapy may be considered the procedure of choice in a variety of situations.Still,as there is no standardized algorithm,local experience should be considered in decision-making.CONCLUSION The treatment of patients with obesity is complex,and a multidisciplinary approach is essential.Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications,and therefore,must be part of the armamentarium in the fight against this disease.

Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis

BACKGROUND Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction(MDBO).AIM To compare the safety and efficacy of plastic stent(PS)vs self-expanding metal stent(SEMS)placement for treatment of MDBO.METHODS This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.A comprehensive search was performed in MEDLINE,Cochrane,Embase,Latin American and Caribbean Health Sciences Literature,and grey literature to identify randomized clinical trials(RCTs)comparing clinical success,adverse events,stent dysfunction rate,reintervention rate,duration of stent patency,and mean survival.Risk difference(RD)and mean difference(MD)were calculated and heterogeneity was assessed with I2 statistic.Subgroup analyses were performed by SEMS type.RESULTS Twelve RCTs were included in this study,totaling 1005 patients.There was no difference in clinical success(RD=-0.03,95%confidence interval[CI]:-0.01,0.07;I 2=0%),rate of adverse events(RD=-0.03,95%CI:-0.10,0.03;I2=57%),and mean patient survival(MD=-0.63,95%CI:-18.07,19.33;I2=54%)between SEMS vs PS placement.However,SEMS placement was associated with a lower rate of reintervention(RD=-0.34,95%CI:-0.46,-0.22;I2=57%)and longer duration of stent patency(MD=125.77 d,95%CI:77.5,174.01).Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS(RD=152.25,95%CI:37.42,267.07;I2=98%and RD=101.5,95%CI:38.91,164.09;I2=98%;respectively).Stent dysfunction was higher in the covered SEMS group(RD=-0.21,95%CI:-0.32,-0.1;I²=205%),with no difference in the uncovered SEMS group(RD=-0.08,95%CI:-0.56,0.39;I²=87%).CONCLUSION While both stent types possessed a similar clinical success rate,complication rate,and patient-associated mean survival for treatment of MDBO,SEMS were associated with a longer duration of stent patency compared to PS.

Effects of intragastric balloon placement in metabolic dysfunctionassociated fatty liver disease: A systematic review and metaanalysis

BACKGROUND Metabolic dysfunction-associated fatty liver disease corresponds to a clinical entity that affects liver function triggered by the accumulation of fat in the liver and is linked with metabolic dysregulation.AIM To evaluate the effects of the intragastric balloon(IGB)in patients with metabolic dysfunction-associated fatty liver disease through the assessment of liver enzymes,imaging and several metabolic markers.METHODS A comprehensive search was done of multiple electronic databases(MEDLINE,EMBASE,LILACS,Cochrane and Google Scholar)and grey literature from their inception until February 2021.Inclusion criteria involved patients with a body mass index>25 kg/m2 with evidence or previous diagnosis of hepatic steatosis.Outcomes analyzed before and after 6 mo of IGB removal were alanine aminotransferase(IU/L),gamma-glutamyltransferase(IU/L),glycated hemoglobin(%),triglycerides(mg/dL),systolic blood pressure(mmHg),homeostatic model assessment,abdominal circumference(cm),body mass index(kg/m2)and liver volume(cm3).RESULTS Ten retrospective cohort studies evaluating a total of 508 patients were included.After 6 mo of IGB placement,this significantly reduced alanine aminotransferase[mean difference(MD):10.2,95%confidence interval(CI):8.12-12.3],gammaglutamyltransferase(MD:9.41,95%CI:6.94-11.88),glycated hemoglobin(MD:0.17%,95%CI:0.03-0.31),triglycerides(MD:38.58,95%CI:26.65-50.51),systolic pressure(MD:7.27,95%CI:4.79-9.76),homeostatic model assessment(MD:2.23%,95%CI:1.41-3.04),abdominal circumference(MD:12.12,95%CI:9.82-14.41)and body mass index(MD:5.07,95%CI:4.21-5.94).CONCLUSION IGB placement showed significant efficacy in improving alanine aminotransferase and gamma-glutamyltransferase levels in patients with metabolic dysfunctionassociated fatty liver disease as well as improving metabolic markers related to disease progression.

Mucosa-associated lymphoid tissue lymphoma in the terminal ileum:A case report

BACKGROUND The lymphoma of the mucosa-associated lymphoid tissue(MALT)is predominantly found in the stomach.The few cases reported in the literature of MALT lymphomas affecting the ileum are in patients who are already symptomatic and with clear advanced endoscopic findings.We present the first case of an asymptomatic female patient who underwent colonoscopy as a routine examination with the findings of an ulcer in the distal ileum region,which histopathological examination and associated immunohistochemistry revealed the diagnosis of MALT lymphoma.CASE SUMMARY A 57-year-old asymptomatic female patient underwent a colonoscopy exam for screening.The examination revealed an ulcer of medium depth with well-defined borders covered by a thin layer of fibrin and a halo of hyperemia in the distal ileum portion.Findings are nonspecific but may signal infections by viruses,protozoa,and parasites or inflammatory diseases such as Crohn's disease.Biopsies of the ulcer were taken.The anatomopathological result revealed an atypical diffuse lymphocytic infiltrate of small cells with a characteristic cytoplasmic halo of marginal zone cells.The immunohistochemical study was performed and the results demonstrated a negative neoplastic infiltrate for the expression of cyclin D1 and cytokeratin AE1/AE3 and a positive for BCL60 in the germinal center.The test also revealed CD10 positivity in the glandular epithelium and germinal center of a reactive follicle with dual-labeling of CD20 and CD3 demonstrating the B lymphocyte nature of the neoplastic infiltrate.In BCL2 protein labeling,the neoplastic infiltrate is strongly positive with a negative germinal center.The findings are consistent with immunophenotype B non-Hodgkin's lymphoma,better classified as extranodal MALT.The patient was treated with chemotherapy and showed complete regression of the disease,as evidenced by colonoscopy performed after treatment.CONCLUSION MALT lymphomas in the terminal ileum are extremely rare and only 4 cases have been reported in the literature.Given the low sensitivity and specificity of endoscopic images in these cases,the pathology can be confused with other important differential diagnoses such as inflammatory diseases or infectious diseases and which makes the biopsy important,even in asymptomatic patients,paired with anatomopathological analysis and immunohistochemistry which is the gold standard for correct diagnosis.