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Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (12)

Background and Aim Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. Methods Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. Results Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74,P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71,P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26,P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70,P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio >= 1.5, and absence of PAD were independent risk factors for PEP. Conclusion Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP ( number: NCT03550768).

"It ain't over horizontal ellipsis till it's over!" Risk-mitigation strategies for patients with gastrointestinal diseases in the aftermath of the COVID-19 pandemic

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (7)

The available COVID-19 literature has focused on specific disease manifestations, infection control, and delivery or prioritization of services for specific patient groups in the setting of the acute COVID-19 pandemic. Local health systems aim to contain the COVID-19 pandemic and hospitals and health-care providers rush to provide the capacity for a surge of COVID-19 patients. However, the short, medium-term, and long-term outcomes of patients with gastrointestinal (GI) diseases without COVID-19 will be affected by the ability to develop locally adapted strategies to meet their service needs in the COVID-19 setting. To mitigate risks for patients with GI diseases, it is useful to differentiate three phases: (i) the acute phase, (ii) the adaptation phase, and (iii) the consolidation phase. During the acute phase, service delivery for patients with GI disease will be curtailed to meet competing health-care needs of COVID-19 patients. During the adaptation phase, GI services are calibrated towards a "new normal," and the consolidation phase is characterized by rapid introduction and ongoing refinement of services. Proactive planning with engagement of relevant stakeholders including consumer representatives is required to be prepared for a variety of scenarios that are dictated by thus far undefined long-term economic and societal impacts of the pandemic. Because substantial changes to the delivery of services are likely to occur, it is important that these changes are embedded into quality and research frameworks to ensure that data are generated that support evidence-based decision-making during the adaptation and consolidation phases.

The risk of acute cholangitis after endoscopic stenting for malignant hilar strictures: A large comprehensive study

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (7)

Background and Aim Endoscopic stenting for unresectable malignant hilar biliary strictures (MHBS) remains challenging. Post-endoscopic retrograde cholangiopancreatography cholangitis (PEC) can be the most common and fatal adverse event. In the present study, we aimed to systematically evaluate the incidence, severity, risk factors, and consequences of PEC after endoscopic procedures for advanced MHBS. Methods Of 924 patients, we identified 502 patients with MHBS (Bismuth types II to IV) who underwent endoscopic stenting as the primary therapy at two centers over 16 years. PEC and its severity were verified according to the current Tokyo guidelines. Results A total of 108 patients (21.5%) experienced acute PEC. Mild, moderate, and severe cholangitis were encountered in 51 (10.1%), 42 (8.4%), and 15 (3.0%) patients, respectively. Multivariate analyses showed that metal stenting (verse plastic stenting) (OR 0.328, 95% CI 0.200-0.535,P < 0.001) and Bismuth classification (IVvsIII/II) (OR 2.499, 95% CI 1.150-5.430) were independent predictors for PEC and the moderate/severe type. Patients with PEC had significantly lower clinical success rates (86.3%vs41.7%,P < 0.001), a higher rate of early death (6.5%vs0.5%,P < 0.001), a shorter median stent patency (4.9vs6.4 months,P < 0.001), and shorter overall survival (2.6vs5.2 months,P < 0.001) compared with the noncholangitis group. Conclusions & xfeff;After endoscopic stenting for advanced MHBS, cholangitis may occur in as many as 21.5% of patients, which may be associated with a poor prognosis. The risk is high in patients with Bismuth type IV and may be reduced by using metal stents.

Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta-analysis

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (11)

Background and Aim Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large colorectal lesions. However, colorectal ESD is associated with a high frequency of adverse events (AEs), and the efficacy of prophylactic endoscopic closure after ESD for preventing AEs is still controversial. This meta-analysis was conducted to assess the efficacy of closure on AEs following colorectal ESD. Methods We searched PubMed, Embase, and the Cochrane Library for eligible studies. The chi-square-based Q statistics and theI(2)test were used to test for heterogeneity. Pooling was conducted using a fixed or random effects model. Results We identified eight eligible studies that compared the effects of closurevsnon-closure with respect to delayed bleeding, delayed perforation, and post-ESD coagulation syndrome. Compared with non-closure (5.2%), closure was associated with a lower incidence (0.9%) of delayed bleeding (pooled odd ratios [ORs]:0.19, 95% CI: 0.08-0.49) following ESD. The pooled ORs showed no significant differences in incidence of delayed perforation (pooled OR: 0.22; 95% CI: 0.05-1.03) or post-ESD coagulation syndrome (pooled OR:0.75; 95% CI: 0.26-2.18) between the closure and non-closure groups. Conclusion Prophylactic endoscopic closure may reduce the incidence of delayed bleeding following ESD of colorectal lesions. Future studies are needed to further illuminate risk factors and stratify high risk subjects for a cost-effective preventive strategy.

High risk of colorectal polyps in men with non-alcoholic fatty liver disease: A systematic review and meta-analysis

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (12)

Background and Aim This meta-analysis aims to explore the risk of colorectal polyps among non-alcoholic fatty liver disease (NAFLD) patients. Methods We searched PubMed, EMBASE, and Cochrane library databases using predefined search term to identify eligible studies (published up to 7 November 2019). Data from selected studies were extracted by using a standardized information collection form, and meta-analyses were performed using random-effects model. The statistical heterogeneity among studies (I-2), subgroup analyses, meta-regression analyses, and the possibility of publication bias were assessed. Results Twenty observational (12 cross-sectional, two case-control, and six cohort) studies met the eligibility criteria, involving 142 387 asymptomatic adults. In cross-sectional/case-control studies, NAFLD was found to be associated with an increased risk of colorectal polyps (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.23-1.47) (including unclassified colorectal polyps, hyperplastic polyps, adenomas, and cancers) with statistically significant heterogeneity (I-2 = 67.8%;P < 0.001). NAFLD was also associated with a higher risk of incident colorectal polyps (hazard ratio = 1.60; 95% CI = 1.36-1.87) with low heterogeneity (I-2 = 21.8%;P = 0.263) in longitudinal studies. The severity of NAFLD was associated with a higher risk of colorectal adenomas (OR = 1.57; 95% CI = 1.30-1.88), but not colorectal cancer (OR = 1.37; 95% CI = 0.92-2.03). The subgroup analysis according to gender showed that NAFLD was significantly associated with a higher risk of colorectal polyps in the male population without significant heterogeneity (OR = 1.47; 95% CI = 1.29-1.67,I-2 = 0%), but not in the female population (OR = 0.88; 95% CI = 0.60-1.29,I-2 = 34.2%). Conclusions NAFLD was associated with an increased risk of colorectal polyps. There was a significant difference of the relationship between genders, which suggested more precise screening colonoscopy recommendation in NAFLD patients according to gender.

Global epidemiology of lean non-alcoholic fatty liver disease: A systematic review and meta-analysis

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (12)

Background and Aim Lean non-alcoholic fatty liver disease (NAFLD) is a potentially metabolically unhealthy state that refers to NAFLD occurring in non-overweight/nonobese subjects. Yet its global epidemiology and metabolic characteristics are not extensively elucidated. Methods PubMed, EMBASE, Web of Science and Cochrane databases were searched for eligible studies until January 2020. Random-effects/fixed-effects models were used to estimate the global prevalence of lean NAFLD and to compare clinical characteristics among lean non-NAFLD, lean NAFLD, and overweight/obese NAFLD subjects. "Lean" NAFLD was defined by ethnic-specific body mass index measurements in the normal range. Meta-regression and subgroup analyses were performed to determine potential sources of heterogeneity. Results A total of 33 observational studies were included with 205 307 individuals from 14 countries. The global prevalence of lean NAFLD was 4.1% (95% confidence interval [CI]: 3.4-4.8%). In lean subjects, the prevalence of NAFLD was 9.7% (95% CI: 7.7-11.8%). The prevalence of lean NAFLD with diabetes, hypertension, metabolic syndrome, dyslipidemia, or central obesity was 0.6% (95% CI: 0.4-0.9%), 1.8% (95% CI: 1.2-2.5%), 1.4% (95% CI: 1.0-1.9%), 2.8% (95% CI: 1.9-3.7%), and 2.0% (95% CI: 1.6-2.4%), respectively. The prevalence of lean NAFLD showed an upward trend between 1988 and 2017. Asian individuals had the highest prevalence of lean NAFLD (4.8%, 95% CI: 4.0-5.6%). Middle-aged people (45-59 years old) had the highest prevalence of lean NAFLD (4.4%, 95% CI: 3.2-5.5%). The prevalence of metabolic complications in lean non-NAFLD, lean NAFLD, and overweight/obese NAFLD groups increased sequentially. Conclusions Lean NAFLD occurs with metabolic complications and is not an uncommon condition. The highest prevalence of lean NAFLD occurs in middle-aged individuals of Asian countries.

Endoscopic ultrasound-guided cyanoacrylate injection to prevent rebleeding in hepatocellular carcinoma patients with variceal hemorrhage

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (12)

Background and Aim Secondary prophylaxis (SP) of variceal rebleeding was reported to improve outcomes of hepatocellular carcinoma (HCC) patients, but the optimal endoscopic approach is not well defined. We compared outcomes in HCC patients who underwent SP by endoscopic ultrasound-guided cyanoacrylate obturation (EUS-CYA)versusno SP. Methods Between 2014 and 2018, 30 consecutive patients with inoperable HCC and recent endoscopically controlled variceal bleeding were prospectively recruited. Twenty-seven patients with persistent varices >= 3 mm on endoscopic ultrasound underwent EUS-CYA for SP. Thirty-three HCC patients treated by esophagogastroduodenoscopy-guided CYA obturation (EGD-CYA) alone for acute variceal bleeding between 2009 and 2013 were identified from a prospective gastrointestinal bleed registry as standard of care controls for comparison. Outcome measures were death-adjusted cumulative incidence of rebleeding, bleeding-free survival, technical success, and procedure-related adverse events of EUS-CYA. Results The majority of patients in both groups had advanced HCC, portal vein thrombosis, and Child-Pugh B cirrhosis. EUS-CYA was successful in all 27 patients with no radiographic evidence of cyanoacrylate-lipiodol embolization. Significantly lower 30- and 90-day death-adjusted cumulative incidence of rebleeding (14.8%vs42.4%,P = 0.023 and 18.5%vs60.6%,P = 0.002, respectively) and significantly higher variceal bleeding-free survival at 3 and 6 months (51.9%vs21.2%,P = 0.009, 40.7%vs15.2%,P = 0.010, respectively) were observed in the EUS-CYA group when compared with standard of care group. Conclusions Secondary prophylaxis by EUS-CYA reduced rebleeding rate and improved variceal bleeding-free survival in patients with inoperable HCC and variceal bleeding when compared with no SP. Randomized studies are needed to confirm the benefits of EUS-CYA for this difficult-to-treat population.

Endocuff-assisted colonoscopyversuscap-assisted colonoscopy for adenoma detection rate: A meta-analysis of randomized controlled trials

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (12)

Background and Aims Add-on devices have been widely used in clinical practice. The aim of this meta-analysis was to compare the adenoma detection rate between Endocuff-assisted colonoscopy (EAC) and cap-assisted colonoscopy (CAC). Methods PubMed, EMBASE, SCOPUS, and Cochrane databases were searched. Outcomes included adenoma detection rate, cecal intubation rate, cecal intubation time, and withdrawal time. Dichotomous data were pooled to obtain the odds ratio or risk ratio. Continuous data were pooled using the mean difference. Results Of the 240 articles reviewed, six randomized controlled trials were included, with a total of 1994 patients. In the meta-analysis, no statistical difference in adenoma detection rate was detected between EAC and CAC (47.0%vs45.1%;P = 0.33). EAC significantly improved detection rate of diminutive adenomas/polyps compared with CAC (P = 0.01). Cecal intubation was achieved in 96.5% in EAC group and 97.9% in CAC group (P = 0.04). Besides, no statistical difference was found in cecal intubation time (P = 0.86), withdrawal time (P = 0.88), small adenomas/polyps (P = 0.60), or large adenomas/polyps (P = 0.95). Conclusion EAC and CAC have their respective merits. EAC significantly improve the detection of diminutive adenomas/polyps. CAC was better in cecal intubation rate.

Association between the methylation of the STAT1 and SOCS3 in peripheral blood and gastric cancer

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (8)

Background and Aim DNA methylation is an important epigenetic modification that can promote the development of various cancers. TheSTAT1andSOCS3have been observed to be hypermethylated in tumor tissues and peripheral blood. This study aimed to explore the relationship between the methylation status of theSTAT1andSOCS3in peripheral blood and gastric cancer (GC). Methods This hospital-based case-control study involved 372 patients with GC and 379 controls. The methylation status of theSTAT1andSOCS3was semiquantitatively determined using the methylation-sensitive high-resolution melting method. Logistic regression analysis was used to analyze the relationship between theSTAT1andSOCS3methylation status and GC susceptibility. Moreover, propensity scores were used to control confounding factors. Results Compared with negative methylation, the positive methylation ofSOCS3significantly increased the risk of GC (ORa = 1.820, 95% CI: 1.247-2.658,P = 0.002). This trend was also found via stratified analysis, and methylation positivity of theSOCS3significantly increased the risk of GC in the < 60 years group, in the >= 60 years group, and in the positiveHelicobacter pyloriinfection group (ORa = 1.654, 95% CI: 1.029-2.660,P = 0.038; ORa = 1.957, 95% CI: 1.136-3.376,P = 0.016; ORa = 2.084, 95% CI: 1.270-3.422,P = 0.004, respectively). Additionally, no significant association was found betweenSTAT1methylation and GC risk (ORa = 0.646, 95% CI: 0.363-1.147,P = 0.135). This study found that the interaction between the methylation status ofSTAT1andSOCS3and environmental factors did not have an impact on GC risk. Conclusion SOCS3methylation may serve as a new potential biomarker for GC susceptibility.

Factors associated with improvement in MELD score after antiviral treatment in patients with chronic hepatitis B

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (9)

Background and Aims Improvement in Model for End-Stage Liver Disease (MELD) score during antiviral treatment is associated with reduced hepatic decompensation and death in patients with chronic hepatitis B (CHB)-related cirrhosis. We aimed to identify factors associated with transplant-free survival and on-treatment MELD score improvement. Methods We identified patients with CHB-related cirrhosis and MELD score >= 15 at the start of entecavir and/or tenofovir disoproxil fumarate treatment between 2005 and 2017. The primary endpoint was transplant-free survival at month 6. The secondary endpoints at month 6 were transplant-free survival with > 5-point improvement in MELD score and transplant-free survival with MELD score Of 999 cirrhotic CHB patients, 605 (60.6%) achieved transplant-free survival at month 6. Proportion of transplant-free survival at month 6 stabilized at 10% in patients with high MELD. Patients who achieved transplant-free survival at month 6 were younger, had lower MELD score, lower alanine aminotransferase (ALT), and higher albumin at baseline. Of 605 patients with transplant-free survival, 276 (45.6%) achieved > 5-point improvement in MELD score; 183 (30.2%) had 1-point to 5-point improvement in MELD score; 146 (24.1%) had no improvement or a worsened MELD score. Also, 321 (53.1%) patients with transplant-free survival had a MELD score < 15 at month 6. Conclusion On top of lower MELD score, patients with CHB-related cirrhosis who are younger, have higher albumin, and lower ALT are more likely to achieve transplant-free survival after 6 months of antiviral treatment.

Risk factors and a predictive nomogram for lymph node metastasis of superficial esophagogastric junction cancer

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (9)

Background and Aim No predictive model for lymph node metastasis (LNM) of superficial esophagogastric junction (EGJ) cancer exists. This study aimed to evaluate incidence, identify risk factors, and develop a predictive nomogram for LNM in patients with superficial EGJ cancers. Methods Data were extracted from the Surveillance, Epidemiology, and End Results database for model development and internal validation. Another data set was obtained from two hospitals for external validation. A nomogram was developed based on independent risk factors that resulted from a multivariate logistic regression analysis. Internal and external validations were performed to assess the performance of nomogram model by receiver operating characteristic and calibration plot. Results Prevalence of LNM was 11.41% for intramucosal cancer and increased to 26.50% for submucosal cancer. On the multivariate analysis, large tumor size (odds ratio [OR] = 1.42;P < 0.001), moderately and poorly/un-differentiated pathological type (OR = 5.62 and 7.67;P = 0.024 and 0.008, respectively), and submucosal invasion (OR = 2.73;P = 0.004) were independent risk factors of LNM. The nomogram incorporating these three predictors demonstrated good discrimination (area under the estimated receiver operating characteristic curve [AUC]: 0.74; 95% confidence interval [95%CI]: 0.68, 0.80) and calibration (mean absolute error was 0.012). Moreover, the discrimination in the internal and external validation sets was good (AUC: 0.73 [95%CI: 0.66, 0.81] and 0.74 [95%CI: 0.60, 0.89], respectively). Nomogram provided better clinical usefulness as assessed by a decision curve analysis. Conclusions Prevalence of LNM in superficial EGJ cancer was high. The first risk-predictive nomogram model for LNM of superficial EGJ cancer may help clinicians to decide optimal treatment option preoperatively.

Efficacy and safety of direct acting antiviral regimens for hepatitis C virus and human immunodeficiency virus co-infection: systematic review and network meta-analysis

期刊: JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, 2020; 35 (9)

Background and Aim Various all-oral direct-acting antiviral (DAA) regimens are being widely used in the treatment of human immunodeficiency virus (HIV)/hepatitis C virus (HCV) co-infected patients; however, the comparative efficacy and safety of different types and combinations of DAAs are not completely clear. There is still a lack of integration of evidence for optimized therapies for HIV/HCV co-infection. Methods We conducted a systematic literature search in several databases up to January 1, 2020. All the studies that reported the sustained virologic response (SVR) and adverse events of DAAs in HIV/HCV co-infected patients were included. The Bayesian Markov Chain Monte Carlo method was used for the pooled estimates of network meta-analysis. Results We identified 33 eligible articles with 7 combinations of all-oral DAAs for the analyses of efficacy and safety. Grazoprevir-elbasvir +/- ribavirin (GZR/EBR +/- RBV: 95.6%; 95% CrI, 91.7-98.1%), ombitasvir/paritaprevir/ritonavir and dasabuvir +/- ribavirin (3D +/- RBV: 95.3%; 95% CrI, 93.4-96.9%), sofosbuvir-ledipasvir +/- ribavirin (SOF/LDV +/- RBV: 95.2%; 95% CrI, 93.7-96.6%), and sofosbuvir-daclatasvir +/- ribavirin (SOF/DCV +/- RBV: 94.8%; 95% CrI, 92.5-96.6%) were the most effective combinations for HIV/HCV co-infected patients, with SVR rates of approximately 94% and above while severe adverse events were rare. However, the SVR rates of sofosbuvir-ribavirin (SOF/RBV) and sofosbuvir-simeprevir +/- ribavirin (SOF/SMV +/- RBV) both failed to reach 90%, and the incidences of adverse events were higher than 5%. Conclusions Efficacy and safety of all-oral DAAs were in prospect for HIV/HCV co-infection patients. GZR/EBR +/- RBV was the optimal combination recommended for HIV/HCV co-infected patients based on the excellent treatment effects and insignificant adverse events.

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