Ameta-analysis on efficacy and safety:single-balloon vs.double-balloon enteroscopy

Background and aim:Double-balloon enteroscopy(DBE)and single-balloon enteroscopy(SBE)are new techniques capable of providing deep enteroscopy.Results of individual studies comparing these techniques have not been able to identify a superior strategy.Our aim was to systematically pool all available studies to compare the efficacy and safety of DBE with SBE for evaluation of the small bowel.Methods:Databases were searched,including PubMed,Embase,and the Cochrane Central Register of Controlled Trials.The main outcome measures were complete small-bowel visualization,diagnostic yield,therapeutic yield,and complication rate.Statistical analysis was performed using Review Manager(RevMan version 5.2).Meta-analysis was performed using fixed-effect or random-effect methods,depending on the absence or presence of significant heterogeneity.We used the v2 and I2 test to assess heterogeneity between trials.Results were expressed as risk ratios(RR)or mean differences with 95%confidence intervals(CI).Results:Four prospective,randomized,controlled trials with a total of 375 patients were identified.DBE was superior to SBE for visualization of the entire small bowel[pooled RR=0.37(95%CI:0.19–0.73;P=0.004)].DBE and SBE were similar in ability to provide diagnosis[pooled RR=0.95(95%CI:0.77–1.17;P=0.62)].There was no significant difference between DBE and SBE in therapeutic yield[pooled RR=0.78(95%CI:0.59–1.04;P=0.09)]and complication rate[pooled RR=1.08(95%CI:0.28–4.22);P=0.91].Conclusions:DBE was superior to SBE with regard to complete small bowel visualization.DBE was similar to SBE with regard to diagnostic yield,ability to provide treatment and complication rate,but these results should be interpreted with caution as they is based on very few studies and the overall quality of the evidence was rated as low tomoderate,due to the small sample size.

Genome-wide gene expression analysis for target genes to differentiate patients with intestinal tuberculosis and Crohn’s disease and discriminative value of FOXP3 mRNA expression

Background and aims:Crohn’s disease(CD)and intestinal tuberculosis(ITB)are both chronic granulomatous conditions with similar phenotypic presentations.Hence,there is need for a biomarker to differentiate between both these two diseases.This study aimed at genome-wide gene expression analysis of colonic biopsies from confirmed cases of ITB and CD in comparison with controls.To evaluate the role of T regulatory cells,forkhead box P3(FOXP3)mRNA expression was quantified in serum as well as in colonic biopsies from patients with ITB and with the controls.Methods:Paired samples,including serum and colonic biopsies,were taken from 33 study subjects(CD,ITB and controls),and total RNA was extracted.Human whole genome gene expression microarray analysis was performed using the Illumina HumanWG-6 BeadChip Kit with six total RNA samples of the three groups in duplicates.Real-time PCR for FOXP3 mRNA expression was analyzed in serum samples and colonic biopsy samples(4-CD,5-ITB,4-controls).Results:In CD and ITB there was 1.5-fold upregulation of 92 and 382 genes and 1.5-fold downregulation of 91 and 256 genes,respectively.Peroxisome proliferators via the PPARc pathway were most significantly downregulated(P<0.005)in CD.Additionally,the IL4/5/6 signaling pathways and Toll-like receptor signaling pathway were identified as significantly differentially regulated(P<0.005)at>2-fold change.In ITB,the complement activation pathway,specifically the classical pathway,was the most significantly upregulated.FOXP3 mRNA expression was significantly elevated in colonic biopsies obtained from ITB patients as compared with CD cases(4.7062.21 vs 1.4860.31,P=0.016).Conclusions:FOXP3 mRNA expression in colonic mucosa could be a discriminatory marker between ITB and CD.Upregulation of the complement activation pathway in ITB suggests that pathogenetic mechanisms for ITB are similar to those of pulmonary tuberculosis.In CD,downregulation of PPARc was seen in colonic tissue,suggesting that restoration of PPARc-dependent anti-microbial barrier function may be a therapeutic target.

Acute pancreatitis associated with intravenous administration of propofol:evaluation of causality in a systematic review of the literature

Acute pancreatitis(AP)associated with intravenous administration of propofol has been described with unknown causal relation.We therefore assessed this causality in a systematic review.Multiple databases were searched on 16 August 2017;studies were appraised and selected by two reviewers based on a priori criteria.Propofol causality was evaluated with the Naranjo scale and Badalov classification.We identified 18 studies from 11 countries with a total of 21 patients,and the majority had adequate methodological quality.The median age was 35 years(range,4–77)and 10(48%)were males.Overall,propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients;median dose was 200 mg,with intermediate latency(1–30 days)in 14(67%).Serum triglycerides were>1000 mg/dL in four patients.Severe AP was observed in four patients(19%).AP recurrence occurred in one out of two patients who underwent rechallenge.Mortality related to AP was 3/21(14%).Propofol was the probable cause of AP according to the Naranjo scale in 19 patients(89%).Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib.Hypertriglyceridemia is not the only mechanism by which propofol illicit AP.Propofol-induced AP was severe in 19%of patients with a mortality rate related to AP of 14%.Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

Why are we performing fewer cholecystectomies for mild acute biliary pancreatitis?Trends and predictors of cholecystectomy from the National Readmissions Database(2010–2014)

Background:Current guidelines recommend cholecystectomy for patients with mild acute biliary pancreatitis(MABP)during the index admission because it is associated with better outcomes.In this study,we aimed to assess national trends in cholecystectomy during index admissions for MABP and to identify factors associated with cholecystectomy completion and 30-day readmission.Methods:Using diagnostic codes and the National Readmissions Database,we identified patients admitted with MABP between 2010 and 2014.Differences in cholecystectomy rates were computed on the basis of various characteristics.We conducted a multivariable analysis to identify factors associated with 30-day readmission and cholecystectomy during the same admission.Results:We identified 255,695 unique index MABP cases(41.3%male)and the 30-day readmission rate was 12.6%.Overall,43.8%underwent cholecystectomy and 25%underwent endoscopic retrograde cholangiopancreatography(ERCP)with sphincterotomy.We observed a decreasing trend in both procedures during the study period(P<0.001).In multivariate analysis,odds of 30-day readmission were reduced for patients undergoing ERCP with sphincterotomy(odds ratio,0.78;95%confidence interval,0.74–0.84)or cholecystectomy(odds ratio,0.37;95%confidence interval,0.35–0.39).Conclusions:For patients with MABP,cholecystectomy or ERCP with sphincterotomy during the index admission decreased the risk of 30-day readmission.Despite this benefit and national guidelines recommending cholecystectomy during the index MABP admission,the rate of cholecystectomies performed nationally decreased during the study period.Further research is needed to understand the implications and reasons underlying this deviation from guidelines.