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.

Validation of genetic variants associated with metabolic dysfunctionassociated fatty liver disease in an ethnic Chinese population

BACKGROUND Genetic factors play an important role in the pathogenesis and development of metabolic dysfunction-associated fatty liver disease(MAFLD).AIM To study the association of single nucleotide polymorphisms(SNPs),previously identified in Western populations,with the risk of MAFLD in a Singapore Chinese population and their interactions with environmental and medical risk factors.METHODS A retrospective case-control study was conducted with 72 MAFLD cases and 72 controls with no hepatic steatosis on computed tomography,magnetic resonance imaging,or controlled attenuation parameter score.Subjects were recruited from two tertiary hospitals.Genetic alleles such as NCAN,GCKR,LYPLAL1,PNPLA3,PPP1R3B,FDFT1,COL13A1,EFCAB4B,PZP,and TM6SF2 were genotyped using the TaqMan®Predesigned SNP Genotyping Assay.RESULTS Weight and body mass index(BMI)were 1.2-times higher in patients(70.6 kg,95%confidence interval[CI]:57.1-84.1 vs 60.8 kg,95%CI:48.5-73.1,P<0.001 and 26.9 kg,95%CI:23-40.8 vs 23.3 kg 95%CI:19-27.6,P<0.001 respectively).The prevalence of diabetes mellitus in patients was 40.3%and 20.8%in controls(P=0.011).Patients had higher mean triglycerides than controls(P<0.001).PNPLA3 GG was more likely to be associated with MAFLD(43.4%CC vs 69.7%GG,P=0.017,and 44.8%CG vs 69.7%GG,P=0.022).In multivariable analysis,hypertriglyceridemia(odds ratio[OR]:2.0495%CI:1.3-3.1,P=0.001),BMI(OR:1.295%CI:1.1-1.4,P<0.001)and PNPLA3 GG(OR:3.495%CI:1.3-9.2,P=0.014)were associated with MAFLD(area under the receiver operating characteristic curve of 0.823).CONCLUSION Among the Chinese population of Singapore,PNPLA3 homozygous GG allele is a strong predictor of MAFLD,whereas LYPLAL1,GCKR,FDFT1,COL13A1,PZP,and TM6SF2 are not significantly associated.Hypertriglyceridemia,high BMI,and PNPLA3 GG are independent predictors of MAFLD.

Risk factors for ribavirin treatment failure in Asian organ transplant recipients with chronic hepatitis E infection

BACKGROUND Hepatitis E virus(HEV)infection is a cause of chronic hepatitis in immunosuppressed patients.Sustained virologic response rates to a 12-wk course of ribavirin therapy were reported to be>70%in the West.This study describes the outcome of HEV treatment in a transplant center in Singapore.AIM To study the outcome of ribavirin treatment in a series of chronic HEV patients,and the cause of treatment failure.METHODS We studied all of the transplant recipients who were diagnosed with HEV infection between 2012 to 2015.The outcome of therapy and virologic relapse are monitored for three years after the end of therapy.RESULTS Ten transplant recipients(4 liver,5 kidney,and 1 bone marrow transplantation)with positive HEV RNA were studied.Nine patients received at least 12 wk of ribavirin therapy,and the remaining patient resolved after reducing immunosuppression therapy.Two subjects had prolonged viremia that lasted more than one year,despite continuous ribavirin therapy.Four ribavirin-treated patients(44.4%)had HEV RNA relapse after achieving a virologic response by the end of treatment.The overall failure rate is 66.7%.Being a kidney transplant recipient is the strongest risk factor for not achieving an initial sustained virologic response(0/5 treated,Chi-Square test,P<0.05).The most common side effect of ribavirin is anemia(100%)(haemoglobin reduction of 3-6.2 g/dL).Seven patients required either a blood transfusion or erythropoietin therapy.CONCLUSION The sustained virologic response rate of 12-wk ribavirin therapy for HEV infection in this Asian series was lower than expected.Kidney transplant recipients had a higher rate of treatment failure due to higher immunosuppression requirements and adverse effects.

Factors early in life associated with hepatic steatosis

BACKGROUND The rise in prevalence of non-alcoholic fatty liver disease(NAFLD)mirrors the obesity epidemic.NAFLD is insidious but may gradually progress from simple steatosis to steatohepatitis,fibrosis and cirrhosis and/or hepatocellular carcinoma.Intervention strategies to ameliorate developmental programming of NAFLD may be more efficacious during critical windows of developmental plasticity.AIM To review the early developmental factors associated with NAFLD.METHODS Databases MEDLINE via PubMed,and EMBASE and Reference Citation Analysis were searched and relevant publications up to April 30,2021 were assessed.Original research studies that included risk factors associated with early development of NAFLD in human subjects were included.These factors include:Maternal factors,intrauterine and prenatal factors,post-natal factors,genetic and ethnic predisposition,childhood and adolescence environmental factors.Studies were excluded if they were review articles or animal studies,case reports or conference abstracts,or if NAFLD was not clearly defined and assessed radiologically.RESULTS Of 1530 citations identified by electronic search,420 duplicates were removed.Of the 1110 citations screened from title and abstract,80 articles were included in the final analysis.Genetic polymorphisms such as patatin-like phospholipase domain-containing protein 3(PNPLA3)and membrane-bound O-acyltransferase domain-containing protein 7(MBOAT7)were associated with increased risk of NAFLD.Familial factors such as maternal obesogenic environment and parental history of hepatic steatosis was associated with offspring NAFLD.Longer duration of exclusive breastfeeding in infancy was associated with a lower risk of developing NAFLD later in life while metabolic dysfunction and/or obesity in adolescence was associated with increased risk of NAFLD.Studies relating to socioeconomic factors and its association with NAFLD reported confounding results.CONCLUSION Maternal metabolic dysfunction during pregnancy,being exclusively breastfed for a longer time postnatally,diet and physical activity in childhood and adolescence are potential areas of intervention to decrease risk of NAFLD.

Clinical utility of non-invasive tests to predict clinical outcomes in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease(NAFLD)is the leading cause of chronic liver disease,and the fastest-growing cause of hepatocellular carcinoma(HCC)worldwide(1,2).As the number of people with NAFLD is too great to perform surveillance in all,risk-stratification strategies are increasingly important to identify those at the highest risk of decompensation and HCC(3,4).