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Prevention of delayed post-polypectomy bleeding by prophylactic clipping after endoscopic colorectal polypectomy: a meta-analysis
Yu Z, Albéniz E, Hu J, Li P, Li Q, Hu Y, Chen J, Wang J
International journal of colorectal disease. 2022
Abstract
PURPOSE This meta-analysis aims to investigate the role of prophylactic clipping after endoscopic colorectal polypectomy or endoscopic mucosal resection (EMR) in prevention of delayed bleeding (DB) following polypectomy. METHODS We searched the PubMed, Embase, and Cochrane Library databases for randomized controlled trials comparing the effect of prophylactic clipping versus no clipping on DB since inception to 22nd April 2022. We then performed a meta-analysis using a random-effects model. RESULTS We included 8 studies with 5648 patients and 10,436 lesions. Prophylactic clipping did not reduce the overall risk of DB compared with no clipping (1.54% vs 2.05%; Log RR, -0.29; 95% confidence interval [CI], -0.59, 0.01; P = 0.06). In subgroup analyses, clipping significantly reduced DB rate in polyps ≥ 2 cm (Log RR, -0.63; 95% CI, -1.08, -0.18; P = 0.01), in non-pedunculated polyps (Log RR, -0.63; 95% CI, -1.01, -0.24; P = 0.00), and in large (≥ 2 cm) proximal polyps (Log RR, -0.81; 95% CI, -1.56, 0.05; P = 0.04), but not in polyps < 2 cm (Log RR, 0.01; 95% CI, -.40, 0.42; P = 0.95). CONCLUSION Prophylactic clipping does not prevent post-polypectomy bleeding after all EMR and should not be performed as a routine practice. Although prophylactic clipping may reduce DB rate following resection of large proximal polyps and non-pedunculated polyps, more high-quality studies are needed to determine the effects of factors such as polyp location, polyp morphology, antithrombotic drug use and complete or partial closure on the effectiveness of prophylactic clipping.
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Sedated second-look endoscopy-guided therapy prevents early rebleeding after variceal ligation for acute variceal bleeding
Wang AJ, Wang J, Zheng XL, Di Liao W, Yu HQ, Gong Y, Gan N, You Y, Guo GH, Xie BS, et al
Journal of digestive diseases. 2020
Abstract
OBJECTIVE The efficacy and safety of second-look endoscopy (SLE)-guided therapy to prevent early post-endoscopic variceal ligation (EVL) bleeding have not been validated. The objective of the study was to determine whether SLE-guided therapy after EVL influences outcomes. METHODS Consecutive cirrhotic patients with large oesophageal varices (EVs) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into the SLE group or non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions and proton pump inhibitor and octreotide administration were used based on the SLE findings. The early post-EVL rebleeding and mortality rates were compared. RESULTS A total of 252 out of 438 patients were included. Early post-EVL rebleeding (13.5% vs. 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs. 0, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, SLE could reduce early rebleeding and mortality rates in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh class B/C (HR: 8.77, P = 0.034), AVB at index EVL (HR: 3.62, P = 0.003), non-selective beta-blocker (NSBB) discontinuation after randomization (HR: 4.68, P = 0.001) and non-SLE (HR: 2.63, P = 0.046) were more likely to have early post-EVL rebleeding. There were no serious adverse events during SLE. CONCLUSION SLE-guided therapy reduces early post-EVL rebleeding and mortality rates in patients with cirrhosis and large EVs receiving EVL for AVB. This article is protected by copyright. All rights reserved.
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3.
Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial
Lv Y, Yang Z, Liu L, Li K, He C, Wang Z, Bai W, Guo W, Yu T, Yuan X, et al
The lancet. Gastroenterology & hepatology. 2019
Abstract
BACKGROUND The survival benefit of early placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and acute variceal bleeding is controversial. We aimed to assess whether early TIPS improves survival in patients with advanced cirrhosis and acute variceal bleeding. METHODS We did an investigator-initiated, open-label, randomised controlled trial at an academic hospital in China. Consecutive patients with advanced cirrhosis (Child-Pugh class B or C) and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy were randomly assigned (2:1) to receive either early TIPS (done within 72 h after initial endoscopy [early TIPS group]) or standard treatment (vasoactive drugs continued to day 5, followed by propranolol plus endoscopic band ligation for the prevention of rebleeding, with TIPS as rescue therapy when needed [control group]). Randomisation was done by web-based randomisation system using a Pocock and Simon's minimisation method with Child-Pugh class (B vs C) and presence or absence of active bleeding as adjustment factors. The primary outcome was transplantation-free survival, analysed in the intention-to-treat population, excluding individuals subsequently found to be ineligible for enrolment. This study is registered with ClinicalTrials.gov, number NCT01370161, and is completed. FINDINGS From June 26, 2011, to Sept 30, 2017, 373 patients were screened and 132 patients were randomly assigned to the early TIPS group (n=86) or to the control group (n=46). After exclusion of three individuals subsequently found to be ineligible for enrolment (two patients in the early TIPS group with non-cirrhotic portal hypertension or hepatocellular carcinoma, and one patient in the control group due to non-cirrhotic portal hypertension), 84 patients in the early TIPS group and 45 patients in the control group were included in the intention-to-treat population. 15 (18%) patients in the early TIPS group and 15 (33%) in the control group died; two (2%) patients in the early TIPS group and one (2%) in the control group underwent liver transplantation. Transplantation-free survival was higher in the early TIPS group than in the control group (hazard ratio 0.50, 95% CI 0.25-0.98; p=0.04). Transplantation-free survival at 6 weeks was 99% (95% CI 97-100) in the early TIPS group compared with 84% (75-96; absolute risk difference 15% [95% CI 5-48]; p=0.02) and at 1 year was 86% (79-94) in the early TIPS group versus 73% (62-88) in the control group (absolute risk difference 13% [95% CI 2-28]; p=0.046). There were no significant differences between the two groups in the incidence of hepatic hydrothorax (two [2%] of 84 patients in the early TIPS group vs one [2%] of 45 in the control group; p=0.96), spontaneous bacterial peritonitis (one [1%] vs three [7%]; p=0.12), hepatic encephalopathy (29 [35%] vs 16 [36%]; p=1.00), hepatorenal syndrome (four [5%] vs six [13%]; p=0.10), and hepatocellular carcinoma (four [5%] vs one [2%]; p=0.68). There was no significant difference in the number of patients who experienced other serious adverse events (ten [12%] vs 11 [24%]; p=0.07) or non-serious adverse events (21 [25%] vs 19 [42%]; p=0.05) between groups. INTERPRETATION Early TIPS with covered stents improved transplantation-free survival in selected patients with advanced cirrhosis and acute variceal bleeding and should therefore be preferred to the current standard of care. FUNDING National Natural Science Foundation of China, National Key Technology R&D Program, Optimized Overall Project of Shaanxi Province, Boost Program of Xijing Hospital.
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The use of adjunctive hemostatic agents in tubeless percutaneous nephrolithotomy: a meta-analysis
Wang J, Zhang C, Tan G, Yang B, Chen W, Tan D
Urolithiasis. 2014;42((6):):509-517.
Abstract
The purpose of the study was to systematically review and assess the safety and efficacy of hemostatic agents in tubeless percutaneous nephrolithotomy. Original studies on the use of hemostatic agents in tubeless percutaneous nephrolithotomy (PCNL) from January 2001 to March 2014 were searched in Ovid, Science Direct, Pubmed, and Embase by two independent reviewers. A drop in hemoglobin (Hb), analgesic requirements, length of hospital stay, and necessity for blood transfusions were compared using Review Manager 5.2. The methods were done according to the Cochrane Handbook for interventional systematic reviews and written based on the PRISMA Statement. Seven studies involving 351 patients met the inclusion criteria for the meta-analysis. The baseline characteristics were comparable in all of the studies. The results showed that the length of hospital stay was less in the experimental group than in the control group (P < 0.05). There were no significant statistical differences in terms of a drop in Hb, analgesic requirements, and the necessity for a blood transfusion between the two groups (P > 0.05). The meta-analysis indicated that the hemostatic agents in tubeless PCNL were not expected to be unsafe or mandatory, but that they were expected to be expensive. We concluded that hemostatic agents might not be necessary in tubeless PCNL.