Annals of Gastroenterology最新文献

Background: Various endoscopic treatment options are available for managing colonic diverticular bleeding (CDB). We conducted a systematic review and meta-analysis to assess the effectiveness of these endoscopic interventions in achieving hemostasis in patients with CDB, focusing on early rebleeding rate (ERR) within 30 days.

Methods: A systematic literature search of the PubMed and Cochrane Library databases was performed for articles published between January 2008 and December 2023. Studies evaluating endoscopic clipping, with or without epinephrine injection, endoscopic band ligation (EBL) and endoscopic snare ligation (EDSL) in the treatment of CDB were included. The primary outcome was the overall pooled ERR following successful hemostasis. Secondary outcomes addressed ERRs associated with various hemostatic endoscopic techniques, and pooled ERRs for both direct and indirect clipping methods. Results are presented as pooled rates and odds ratio (OR) with 95% confidence intervals (CI).

Results: Sixteen studies were included, comprising 1435 patients with definite CDB of whom 1273 received endoscopic hemostatic treatment. Overall pooled ERR was 14.73% (95%CI 9.33-20.14%). Pooled ERRs were 9.83% (95%CI 7.41-12.26%) in the EBL/EDSL group and 22.32% (95%CI 12.48-32.16%) in the endoscopic clipping group (P=0.02). A subgroup analysis of the clipping group showed a significant difference between the pooled ERRs favoring direct clipping: 12.04% (95%CI 3.06-21.02%) vs. 27.74% (95%CI 18.34-37.14%), P=0.02. The measured effect favors direct over indirect clipping in reducing early rebleeding episodes: OR 0.45, 95%CI 0.24-0.85; P=0.01.

Conclusion: In the management of patients presenting with CDB, EBL/EDSL and direct clipping showed significantly lower ERRs compared to indirect clipping.

Background: We performed a meta-analysis to assess the effect of non-pharmacological techniques, such as virtual reality (VR) and music, as adjuncts to sedation administration during gastrointestinal (GI) endoscopic procedures.

Methods: We performed a systematic review across MEDLINE and Cochrane Central Register libraries of randomized controlled trials (RCTs), published between 2014 and 2024, evaluating how non-pharmacological techniques affected patients' reported pain (primary outcome), and anxiety and satisfaction (secondary outcomes), during endoscopy. We performed pairwise meta-analyses and expressed the effect size on study outcomes. We assessed the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation approach.

Results: Twelve RCTs analyzing outcomes from 1511 patients (non-pharmacological techniques n=762; standard sedation n=749) were included. Compared to the sedation-only group, application of non-pharmacological techniques resulted overall in significantly lower pain as mean difference [MD] -1.02, 95% confidence interval [CI] -1.64 to -0.41; I ² =64%) and anxiety (MD -1.07, 95%CI -1.75 to -0.39; I ² =20%), with higher satisfaction (MD 1.67, 95%CI 0.50-2.84; I ² =94%). There was low confidence in the estimates, due to the possibility of performance and detection bias in the majority of the studies, and the high level of heterogeneity. This effect regarding reported pain was consistent for virtual reality (3 RCTs, n=241) and music (10 RCTs, n=1270): MD -1.05, 95%CI -1.74 to -0.37; I² =0%, and MD -1.00, 95%CI -1.80 to -0.20; I² =73%, respectively.

Conclusion: Concomitant application of virtual reality and/or music as adjuncts to sedation administration during GI endoscopic procedures decreases pain and anxiety, at the same improving time patient satisfaction.

Background: Endoscopic treatments of symptomatic Zenker's diverticulum (ZD) include flexible endoscopic septotomy (FES) and, more recently, peroral endoscopic myotomy (Z-POEM). Data comparing these techniques are limited. We conducted a meta-analysis evaluating FES vs. Z-POEM for symptomatic ZD.

Methods: Multiple databases were searched from inception to September 2024. Our primary outcomes were clinical and technical success. Secondary outcomes included adverse events, length of hospital stay (LOS), procedure time, and recurrence. A random-effects model was used, and outcomes were represented as pooled rates, relative risk (RR) and standardized mean difference (SMD), along with 95% confidence intervals (CI).

Results: Seven studies with 580 patients (Z-POEM=274, FES=306) were included. Mean age ranged from 68.9-74.9 years. The diverticulum size was not statistically different between the 2 groups: SMD -3.78 (-11.68 to 4.12), P=0.35. The pooled technical success was similar for Z-POEM and FES: RR 0.99 (95%CI 0.96-1.02; I ²=0%); P=0.4. Clinical success rate was significantly higher for Z-POEM compared to FES: RR 1.11 (95%CI 1.04-1.18; I ²=16%); P=0.001. There were no statistically significant differences between the 2 treatment modalities in pooled rate of recurrence, adverse events, LOS or procedural time.

Conclusions: Our analysis shows that Z-POEM and FES in the treatment of symptomatic ZD are both associated with high technical success and a good safety profile, and have comparable procedural times and rates of recurrence. Z-POEM may offer higher rates of clinical success at follow up.

Background: Data on the potential association between diverticulosis and colonic neoplastic lesions are still controversial. We investigated this issue in subjects who underwent screening colonoscopy.

Methods: We reviewed the data of subjects with a positive fecal immunological test who underwent a first colonoscopy in the national colorectal screening program. Endoscopic and histological reports were evaluated, using both univariate and multivariate analyses to search for an association between diverticulosis and colonic neoplastic lesions.

Results: Data from 5050 subjects (males: 52.2%; mean age: 61.7±6.5 years) observed in the 7 participating centers were considered. Diverticula were found in 2176 (43.1%) cases; at least 1 adenoma was detected in 2277 (45.1%) patients, at least 1 advanced adenoma in 842 (16.7%); and cancer was diagnosed in 159 (3.1%) cases. By univariate analysis, the prevalence of adenomas in patients with diverticula (46.7%, 95% confidence interval [CI] 44.6-48.8%) was significantly higher than in controls (43.8%, 95%CI 42.1-45.7%; P=0.041), while prevalences of both advanced adenomas (13.8%, 95%CI 16.3-19.5%) and cancers (2.4%, 95%CI 1.7-3.1% vs. 3.7%, 95%CI 3.1-4.4%) were lower. By multivariate analysis, only male sex (odds ratio [OR] range: 1.54-2.05) and age (OR range: 1.03-1.05) were found to be independent variables associated with different neoplastic lesions in the colon, whilst diverticulosis was not.

Conclusion: This large, multicenter study found no significant association between diverticulosis and neoplastic lesions in subjects who underwent screening colonoscopy.

Gallstones are primarily crystalline cholesterol formations that may present significant medical concerns, often leading to bile duct obstruction. Their genesis is multifaceted, influenced by genetics, diet and age. Over the decades, the biliary stone management domain has undergone a transformation, propelled by clinical demands and technological advances. This review focuses on percutaneous treatments, highlighting the shift from foundational percutaneous transhepatic cholangiography to advanced percutaneous transhepatic cholangioscopy, emphasizing patient safety, efficacy, and outcomes. The significance of patient-reported outcomes, capturing aspects that include pain and post-intervention quality of life, is accentuated. A critical analysis reveals a gap in our understanding of the long-term resilience of percutaneous interventions, particularly with respect to averting stone recurrence or treating chronic strictures. The potential of technological enhancements, including advanced endoscopes and real-time imaging, is acknowledged, though the need for rigorous clinical validation must be stressed. Decision-making challenges, due to the myriads of available interventions, are highlighted, emphasizing the need for evidence-based algorithms. Economically, the cost dynamics, both direct and ancillary, of these interventions come to the forefront. Concluding, the paper advocates for continuous innovation, ensuring that biliary stone management remains efficient, patient-centered, safe, and economically justified.

Background: The impairment of gastrointestinal mucosa visibility during esophagogastroduodenoscopy (EGD), due to the presence of foam and bubbles, may lead to reduced quality in the EGD results. The combination of simethicone, a defoaming agent, along with N-acetylcysteine (NAC), which has mucolytic properties, has been proposed to improve the visibility of the mucosa. This study aimed to evaluate the effectiveness of pre-procedural administration of simethicone and N-acetylcysteine in improving mucosal visibility, procedure time and mucosal cleansing volume needed during EGD.

Methods: We conducted a comprehensive literature search from inception to November 23, 2023, in PubMed, CENTRAL, ProQuest, SAGE, and JSTOR. We included randomized clinical trials that investigated the effects of simethicone with or without NAC as premedication in EGD. For the quantitative analysis, standardized mean difference (SMD) was used to assess continuous outcomes and risk ratio for dichotomous outcomes. The Cochrane risk of bias 2 tool was used to evaluate the risk of bias.

Results: This meta-analysis comprised a total of 20 studies and found that simethicone with or without NAC improved mucosal visibility compared with control (SMD -1.27, 95% confidence interval [CI] -1.74 to -0.81, P<0.001). The combination of simethicone and NAC was significantly better than simethicone alone (SMD -0.68, 95%CI -1.08 to -0.28, P=0.001). Simethicone with or without NAC also shortened the procedure time compared to control (MD -1.40, 95%CI -2.67 to -0.12, P=0.03). The risk of bias was low with a moderate grade of certainty.

Conclusion: The administration of simethicone with or without NAC may improve EGD quality.

Background: Cachexia is a detrimental multifactorial syndrome that has been strongly associated with cancer. A growing body of data concerning its management is being generated from the ongoing advances of experimental cancer cachexia research. This study aimed to delineate the broad landscape of cancer cachexia research, by comprehensively presenting the treatment interventions and targets of cancer cachexia during the past decade.

Methods: A systematic literature search was performed in Medline and Scopus databases from January to April 2023. Articles were considered eligible if they described any type of intervention in tumor-bearing rodents to study the effect on prevention or treatment of cancer cachexia. The corresponding signaling and metabolic pathways that were targeted by these interventions were documented.

Results: A total of 271 articles were considered eligible for our study. Of these, 176 studies pertained to pharmaceutical interventions with 100 corresponding targets, 58 studies pertained to nutritional interventions with 60 corresponding targets, and 37 studies pertained to exercise interventions with 60 corresponding targets.

Conclusions: The continuous evolution of cancer cachexia research has provided a plethora of disease targets and corresponding treatment interventions. Moving forward, the available management strategies should be refined and clinical research should efficiently capitalize on the robust experimental evidence.

Background: The risk of gastrointestinal (GI) cancer after lung transplantation (LTx) in sarcoidosis patients is not well defined. Given the cancer risks linked to sarcoidosis and organ transplantation, this study investigated the incidence of GI de novo malignancies (DNM), comparing LTx recipients with sarcoidosis or idiopathic pulmonary fibrosis (IPF).

Methods: We analyzed data from the United Network for Organ Sharing registry, including adults with sarcoidosis or IPF who underwent LTx between May 2005 and December 2018. The primary outcome was the incidence of GI DNM by March 2023.

Results: Of 7996 lung transplant recipients, 108 (1.35%) developed GI malignancies post-transplantation. Among these, 662 patients (9%) had sarcoidosis and 7334 (91%) had IPF. Sarcoidosis patients showed a non-significant trend toward a higher risk of GI malignancies compared to those with IPF (subhazard ratio 1.72, 95% confidence interval 0.90-3.29; P=0.099), with no observed difference in the risk of non-GI cancers.

Conclusions: The overall incidence of GI DNM following LTx is low, and sarcoidosis does not appear to increase the risk of GI cancers compared to IPF. This finding suggests that enhanced GI cancer screening beyond standard guidelines may not be warranted in this population, allowing for targeted surveillance of more prevalent malignancies in sarcoidosis patients post-LTx.

Background: Fatty changes in the pancreas are common, whereas total pancreatic lipomatosis (PL) is rare. Commonly associated with various components of metabolic syndrome and metabolic-associated steatotic liver disease, total PL can have various etiologies and can manifest with severe pancreatic exocrine insufficiency.

Method: We retrospectively analysed the clinical profile and management outcomes of 8 patients (mean age: 37.1 years; 5 male) with total PL seen at a tertiary care center over the last 15 years.

Results: All patients presented with abdominal pain and had coexistent chronic pancreatitis, while 5/8 (62%) patients had metabolic syndrome. None of the patients had a history of acute pancreatitis or congenital syndromes, nor developed pancreatic carcinoma in the follow up. Seven (87%) patients had pancreatic ductal dilatation and calcification. All patients had pancreatic exocrine insufficiency, while 5/8 (52%) patients had endocrine insufficiency. Six (75%) patients were successfully managed with pancreatic endotherapy.

Conclusions: Pancreatic endotherapy is safe and effective in the treatment of abdominal pain in patients who have chronic pancreatitis with total PL. These patients have a high frequency of pancreatic exocrine as well as endocrine insufficiency.