Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal polyps:A meta-analysis and metaregression with single arm analysis

BACKGROUND Endoscopic submucosal dissection(ESD)has shown to be effective in management of colorectal neoplasm in the Asian countries,while its implementation in Western countries where endoscopic mucosal resection(EMR)is preferred is still debatable.AIM To compare the surgical,histological,and oncological outcomes between ESD and EMR in the treatment of colorectal polyps,with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world.METHODS Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc,complete resection,margin involvement,resection time,need for additional surgery,complications,and recurrence rate of ESD with EMR.RESULTS Of 281344 colorectal polyps from 21 studies were included.When compared to EMR,the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate,and lower lateral margin involvement and recurrence.ESD led to increased procedural time,need for additional surgery,and perforation risk.No significant difference in bleeding risk was found between the two groups.Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD.Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate,bleeding risk and recurrence.In subgroup analysis,Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4%and 0.0002%,respectively,as compared to perforation risk of 8%and 1%,respectively,in reports coming from rest of the world.CONCLUSION ESD resulted in better resection outcomes and lower recurrence compared to EMR.With appropriate training,ESD is preferred over EMR as the first-line therapy for resection of colorectal polyps,without restricting to lesions greater than 20 mm and those with high suspicion of submucosal invasion.

Foregut bypass vs.restrictive bariatric procedures for nonalcoholic fatty liver disease:a meta-analysis of 3,355 individuals

Background:Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease(NAFLD).However,there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters,especially for histological outcomes.Thus,this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic,biochemical,and histological parameters for patients with NAFLD.Methods:Medline and Embase were searched for articles relating to bariatric procedures and NAFLD.Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre-vs.post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.Results:Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures(n=1,460)and foregut bypass(n=1,895)were included.Both foregut bypass(P<0.01)and restrictive procedures(P=0.03)significantly increased odds of fibrosis resolution.Compared to restrictive procedures,foregut bypass resulted in a borderline non-significant decrease in fibrosis score(P=0.06)and significantly lower steatosis score(P<0.001).For metabolic parameters,foregut bypass significantly lowered body mass index(P=0.003)and low-density lipoprotein(P=0.008)compared to restrictive procedures.No significant differences were observed between both procedures for aspartate aminotransferase(P=0.17)and alkaline phosphatase(P=0.61).However,foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures(P=0.01)while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass(P=0.02).Conclusions:The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.

Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria:a meta-analysis of 18,421 patients

Background:Outcomes after liver resection(LR)and liver transplantation(LT)for hepatocellular carcinoma(HCC)are heterogenous and may vary by region,over time periods and disease burden.We aimed to compare overall survival(OS)and disease-free survival(DFS)between LT versus LR for HCC within the Milan criteria.Methods:Two authors independently searched Medline and Embase databases for studies comparing survival after LT and LR for patients with HCC meeting the Milan criteria.Meta-analyses and meta-regression were conducted using random-effects models.Results:We screened 2,278 studies and included 35 studies with 18,421 patients.LR was associated with poorer OS[hazard ratio(HR)=1.44;95%confidence interval(CI):1.14-1.81;P<0.01]and DFS(HR=2.71;95%CI:2.23-3.28;P<0.01)compared to LT,with similar findings among intention-to-treat(ITT)studies.In uninodular disease,OS in LR was comparable to LT(P=0.13)but DFS remained poorer(HR=2.95;95%CI:2.30-3.79;P<0.01).By region,LR had poorer OS versus LT in North America and Europe(P≤0.01),but not Asia(P=0.25).LR had inferior survival versus LT in studies completed before 2010(P=0.01),but not after 2010(P=0.12).Cohorts that underwent enhanced surveillance had comparable OS after LT and LR(P=0.33),but cohorts undergoing usual surveillance had worse OS after LR(HR=1.95;95%CI:1.24-3.07;P<0.01).Conclusions:Mortality after LR for HCC is nearly 50%higher compared to LT.Survival between LR and LT were similar in uninodular disease.The risk of recurrence after LR is threefold that of LT.

A Class Effect Network Meta-analysis of Lipid Modulation in Non-alcoholic Steatohepatitis for Dyslipidemia

Background and Aims:Pharmaceutical therapy for NASH is associated with lipid modulation,but the consensus on drug treatment is limited and lacks comparative analysis of effectiveness.A network meta-analysis was conducted to compare NASH drug classes in lipid modulation.Methods:Online databases were searched for randomized controlled trails(RCTs)evaluating NASH treatments in biopsy-proven NASH patients.Treatments were classified into four groups:(1)inflammation,(2)energy,(3)bile acids,and(4)fibro-sis based on the mechanism of action.A Bayesian network analysis was conducted with outcome measured by mean difference(MD)with credible intervals(Crl)and surface un-der the cumulative ranking curve(SUCRA).Results:Forty-four RCTs were included in the analysis.Bile acid modulat-ing treatments(MD:0.05,Crl:0.03-0.07)were the best treatment for improvement in high-density lipid(HDL)cho-lesterol,followed by treatments modulating energy(MD:0.03,Crl:0.02-0.04)and fibrosis(MD:0.01,Crl:−0.12 to 0.14)compared with placebo.The top three treatments for reduction in triglycerides were treatments modulating energy(MD:−0.46,Crl:−0.49 to−0.43),bile acids(MD:−0.22,Crl:−0.35 to−0.09),and inflammation(MD:−0.08,Crl:−0.13 to−0.03)compared with placebo.SUCRA found treatment modulating fibrosis(MD:−1.27,Crl:−1.76 to−0.79)was the best treatment for reduction in low-density lipid(LDL)cholesterol followed by treatment modulating in-flammation(MD:−1.03,Crl:−1.09 to−0.97)and energy(MD:−0.37,Crl:−0.39 to−0.34)compared with placebo,but LDL cholesterol was worsened by treatments modulat-ing bile acids.Conclusions:Network analysis comparing the class effects of dyslipidemia modulation in NASH found that treatment targets can include optimization of athero-genic dyslipidemia.Future studies are required to evaluate the cardiovascular outcomes.