Endoscopic ultrasound artificial intelligence-assisted for prediction of gastrointestinal stromal tumors diagnosis:A systematic review and meta-analysis

BACKGROUND Subepithelial lesions(SELs)are gastrointestinal tumors with heterogeneous malignant potential.Endoscopic ultrasonography(EUS)is the leading method for evaluation,but without histopathological analysis,precise differentiation of SEL risk is limited.Artificial intelligence(AI)is a promising aid for the diagnosis of gastrointestinal lesions in the absence of histopathology.AIM To determine the diagnostic accuracy of AI-assisted EUS in diagnosing SELs,especially lesions originating from the muscularis propria layer.METHODS Electronic databases including PubMed,EMBASE,and Cochrane Library were searched.Patients of any sex and>18 years,with SELs assessed by EUS AIassisted,with previous histopathological diagnosis,and presented sufficient data values which were extracted to construct a 2×2 table.The reference standard was histopathology.The primary outcome was the accuracy of AI for gastrointestinal stromal tumor(GIST).Secondary outcomes were AI-assisted EUS diagnosis for GIST vs gastrointestinal leiomyoma(GIL),the diagnostic performance of experienced endoscopists for GIST,and GIST vs GIL.Pooled sensitivity,specificity,positive,and negative predictive values were calculated.The corresponding summary receiver operating characteristic curve and post-test probability were also analyzed.RESULTS Eight retrospective studies with a total of 2355 patients and 44154 images were included in this meta-analysis.The AI-assisted EUS for GIST diagnosis showed a sensitivity of 92%[95%confidence interval(CI):0.89-0.95;P<0.01),specificity of 80%(95%CI:0.75-0.85;P<0.01),and area under the curve(AUC)of 0.949.For diagnosis of GIST vs GIL by AI-assisted EUS,specificity was 90%(95%CI:0.88-0.95;P=0.02)and AUC of 0.966.The experienced endoscopists’values were sensitivity of 72%(95%CI:0.67-0.76;P<0.01),specificity of 70%(95%CI:0.64-0.76;P<0.01),and AUC of 0.777 for GIST.Evaluating GIST vs GIL,the experts achieved a sensitivity of 73%(95%CI:0.65-0.80;P<0.01)and an AUC of 0.819.CONCLUSION AI-assisted EUS has high diagnostic accuracy for fourth-layer SELs,especially for GIST,demonstrating superiority compared to experienced endoscopists’and improving their diagnostic performance in the absence of invasive procedures.

Endoscopic vs radiologic gastrostomy for enteral feeding:A systematic review and meta-analysis

BACKGROUND Percutaneous endoscopic gastrostomy(PEG)and percutaneous radiological gastrostomy(PRG)are minimally invasive techniques commonly used for prolonged enteral nutrition.Despite safe,both techniques may lead to complications,such as bleeding,infection,pain,peritonitis,and tube-related complications.The literature is unclear on which technique is the safest.AIM To establish which approach has the lowest complication rate.METHODS A database search was performed from inception through November 2022,and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.All included studies compared the two techniques directly and provided absolute values of the number of complications.Studies with pediatric populations were excluded.The primary outcome of this study was infection and bleeding.Pneumonia,peritonitis,pain,and mechanical complications were secondary outcomes.The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials(RoB2)and we used The Risk of Bias in Nonrandomized Studies(ROBINS-I)to analyze the retrospective studies.We also performed GRADE analysis to assess the quality of evidence.Data on risk differences and 95%confidence intervals were obtained using the Mantel-Haenszel test.RESULTS Seventeen studies were included,including two randomized controlled trials and fifteen retrospective cohort studies.The total population was 465218 individuals,with 273493 having undergone PEG and 191725 PRG.The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG(95%CI:0.03 to 0.08;P<0.00001),although this outcome did not show significant difference in randomized studies(95%CI:-0.07 to 0.04;P=0.13).There was no difference in the analyses of the following outcomes:infection in retrospective(95%CI:-0.01 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.04;P=0.44)studies;bleeding in retrospective(95%CI:-0.00 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.02;P=0.43)studies;pneumonia in retrospective(95%CI:-0.04 to 0.00;P=0.28)or randomized(95%CI:-0.09 to 0.11;P=0.39)studies;pain in retrospective(95%CI:-0.05 to 0.02;P<0.00001)studies;peritonitis in retrospective(95%CI:-0.02 to 0.01;P<0.0001)studies.CONCLUSION PEG has lower levels of tube-related complications(such as dislocation,leak,obstruction,or breakdown)when compared to PRG.

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis

AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P < 0.00001) and fewer re-interventions(21.6% vs 56.6%, P < 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P < 0.0001), with a higher patency period(250 d vs 124 d, P < 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P < 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.

Endoscopy vs surgery in the treatment of early gastric cancer:Systematic review

AIM: To report a systematic review,establishing the available data to an unpublished 2a strength of evidence,better handling clinical practice.METHODS: A systematic review was performed using MEDLINE,EMBASE,Cochrane,LILACS,Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants,inclusion and exclusion criteria,interventions(mainly,mucosal resection and submucosal dissection vs surgical approach) and outcomes(adverse events,different survival rates,mortality,recurrence and complete resection rates). To ascertain the validity of eligible studies,the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software Rev Man,by computingrisk differences(RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%,a subsequent assay was done and other findings were compiled.RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Threeyear survival data were available for six studies(n = 1197). There were no risk differences(RD) after endoscopic and surgical treatment(RD = 0.01,95%CI:-0.02-0.05,P = 0.51). Five-year survival data(n = 2310) showed no difference between the two groups(RD = 0.01,95%CI:-0.01-0.03,P = 0.46). Recurrence data were analized in five studies(1331 patients) and there was no difference between the approaches(RD = 0.01,95%CI:-0.00-0.02,P = 0.09). Adverse event data were identified in eight studies(n = 2439). A significant difference was detected(RD =-0.08,95%CI:-0.10--0.05,P < 0.05),demonstrating better results with endoscopy. Mortality data were obtained in four studies(n = 1107). There was no difference between the groups(RD =-0.01,95%CI:-0.02-0.00,P = 0.22).CONCLUSION: Three-,5-year survival,recurrence and mortality are similar for both groups. Considering complication,endoscopy is better and,analyzing complete resection data,it is worse than surgery.

Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones:A systematic review and meta-analysis based on randomized controlled trials

AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials(RCTs) on Med Line, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy(ML), perforation and cholangitis. RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography(ERCP) bleeding [FE RD-0.02, CI(-0.03,-0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI(-0.25,-0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI(-0.38,-0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI(-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI(-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI(-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI(-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI(-0.02, 0.07), I2 = 11%, P = 0.31]. CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.

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.

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.

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.

Antibiotic prophylaxis to prevent complications in endoscopic retrograde cholangiopancreatography:A systematic review and meta-analysis of randomized controlled trials

BACKGROUND The prophylactic use of antibiotics in endoscopic retrograde cholangiopancreatography(ERCP)is still controversial.AIM To assess whether antibiotic prophylaxis reduces the rates of complications in patients undergoing elective ERCP.METHODS This systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.A comprehensive search of multiple electronic databases was performed.Only randomized controlled trials were included.The outcomes analyzed included bacteremia,cholangitis,sepsis,pancreatitis,and mortality.The risk of bias was assessed by the Cochrane revised Risk-of-Bias tool for randomized controlled trials.The quality of evidence was assessed by the Grading of Recommendation Assessment,Development,and Evaluation.Meta-analysis was performed using the Review Manager 5.4 software.RESULTS Ten randomized controlled trials with a total of 1757 patients that compared the use of antibiotic and non-antibiotic prophylaxis in patients undergoing elective ERCP were included.There was no significant difference between groups regarding incidence of cholangitis after ERCP[risk difference(RD)=-0.02,95%confidence interval(CI):-0.05,0.02,P=0.32,cholangitis in patients with suspected biliary obstruction(RD=0.02,95%CI:-0.08 to 0.13,P=0.66),cholangitis on intravenous antibiotic prophylaxis(RD=-0.02,95%CI:-0.05 to 0.01,P=0.25),septicemia(RD=-0.02,95%CI:-0.06 to 0.01,P=0.25),pancreatitis(RD=-0.02,95%CI:-0.06 to 0.01,P=0.19),and allcause mortality(RD=0.00,95%CI:-0.01 to 0.01,P=0.71).However,the antibiotic prophylaxis group presented a 7%risk reduction in the incidence of bacteremia(RD=-0.07,95%CI:-0.14 to-0.01,P=0.03).CONCLUSION The prophylactic use of antibiotics in patients undergoing elective ERCP reduces the risk of bacteremia but does not appear to have an impact on the rates of cholangitis,septicemia,pancreatitis,and mortality.

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.

Treatment of high-grade dysplasia and intramucosal carcinoma using radiofrequency ablation or endoscopic mucosal resection + radiofrequency ablation: Meta-analysis and systematic review

BACKGROUND The progression of Barrett's esophagus(BE) to early esophageal carcinoma occurs sequentially; the metaplastic epithelium develops from a low-grade dysplasia to a high-grade dysplasia(HGD), resulting in early esophageal carcinoma and,eventually, invasive carcinoma. Endoscopic approaches including resection and ablation can be used in the treatment of this condition.AIM To compare the effectiveness of radiofrequency ablation(RFA) vs endoscopic mucosal resection(EMR) + RFA in the endoscopic treatment of HGD and intramucosal carcinoma.METHODS In accordance with PRISMA guidelines, this systematic review included studies comparing the two endoscopic techniques(EMR + RFA and RFA alone) in the treatment of HGD and intramucosal carcinoma in patients with BE. Our analysis included studies involving adult patients of any age with BE with HGD or intramucosal carcinoma. The studies compared RFA and EMR + RFA methods were included regardless of randomization status.RESULTS The seven studies included in this review represent a total of 1950 patients, with742 in the EMR + RFA group and 1208 in the RFA alone group. The use of EMR +RFA was significantly more effective in the treatment of HGD [RD 0.35(0.15,0.56)] than was the use of RFA alone. The evaluated complications(stenosis,bleeding, and thoracic pain) were not significantly different between the two groups.CONCLUSION Endoscopic resection in combination with RFA is a safe and effective method in the treatment of HGD and intramucosal carcinoma, with higher rates of remission and no significant differences in complication rates when compared to the use of RFA alone.

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.

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.