Abstract

BACKGROUND AND AIMS Despite advances in endoscopic therapies, malignancy-related gastrointestinal (GI) bleeding remains difficult to manage with high rates of treatment failure and rebleeding. Topical hemostatic agents (THA) are easier to apply to the wide bleeding surface of tumors. We conducted this systematic review and meta-analysis to evaluate the efficacy of THAs in malignancy-related GI bleed. METHODS We conducted a comprehensive search of multiple electronic databases to identify studies reporting on the use of THAs in malignancy-related GI bleeding. The primary outcome was the achievement of hemostasis; secondary outcomes were early rebleeding (≤ 3 days), delayed rebleeding (>3 days), aggregate rebleeding, all-cause mortality, and GI bleed related mortality. A meta-analysis of proportions was done for all outcomes. RESULTS Out of 355 citations, total 16 studies with 530 patients were included. Primary hemostasis was achieved in 94.1% (95% CI: 91.5 - 96.0%). Early rebleeding was seen in 13.9% (95% CI: 9.7 - 19.4%) while delayed rebleeding was seen in 11.4% (95% CI: 5.8 - 21.1%). Aggregate rebleeding was seen in 24.2% (95% CI:18.5 - 31.0%). All-cause mortality was 33.1% (95% CI: 23.7 - 44.0%) while GI bleed related mortality occurred in 5.9% (95% CI: 2.2% - 14.8%). CONCLUSIONS THAs are highly effective for achieving primary hemostasis in malignancy-related GI bleeding. It should be considered as an alternative to traditional endotherapy methods in malignancy-related GI bleeds. Future studies should be designed to evaluate its efficacy and safety as a primary method of hemostasis as compared to traditional endotherapy measures.

Abstract

GOALS/BACKGROUND Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. STUDY We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. RESULTS A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. CONCLUSIONS Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.

Abstract

Efficacy and Safety of intravenous albumin for non-spontaneous bacterial peritonitis infection among patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials INTRODUCTION Bacterial infection is a common cause of acute-on-chronic liver failure (ACLF) and death among cirrhosis. The benefit of intravenous (IV) albumin among cirrhosis with non-SBP infection remains unclear as individual studies are underpowered to detect the survival benefit of IV albumin. AIM: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of intravenous albumin for non-SBP infection among cirrhosis patients. METHODS We performed a systematic search of electronic databases (Pubmed, MEDLINE and Clinicalkey) up to 1(st) December 2019. Studies evaluating IV albumin for non-SBP infection were selected. Using random effect model, the pooled odds ratio (OR), 95% confidence interval (95%CI) and heterogeneity were assessed. RESULTS A total of 3 RCTs (406 subjects) fulfilling the inclusion criteria among 218 citations were identified. There was no significant heterogeneity across included studies. In this meta-analysis, we found that the pooled risk of renal impairment (RI) (OR=0.58, 95%CI: 0.28-1.23, I(2)=0%), mortality at 30 days (OR=1.61, 95%CI: 0.87-3.00, I(2)=0%) as well as mortality at 90 days (OR=1.30, 95%CI: 0.81-2.07, I(2)=0%) were similar between albumin and control group. Pooled event of pulmonary edema occurred more commonly in albumin group (OR 5.17, 95%CI 1.62-16.47, I(2)=0%). More subjects achieved resolution of ACLF in IV albumin group as compared to control group (OR=0.11, 95%CI: 0.02-0.69, p=0.02). CONCLUSION Albumin did not reduce the risk of RI and mortality, yet increases the risk of pulmonary edema. Albumin may promote recovery of ACLF, however, more data is required to validate this benefit.

Abstract

Background and study aims Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a "bridge" therapy. However, their role in the treatment protocol is not established due to paucity in data. Methods We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all-cause mortality, immediate bleeding control and rebleeding rates. Results Five hundred forty-seven patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS 9 studies, 398 patients). The pooled rate of all-cause mortality with SEMS was 43.6 % (95 % CI 28.6-59.8, I (2) = 38) and with TIPS was 27.9 % (95 % CI 16.3-43.6, I (2) = 91). The pooled rate of immediate bleeding control with SEMS was 84.5 % (95 % CI 74-91.2, I (2) = 40) and with TIPS was 97.9 % (95 % CI 87.7-99.7, I (2) = 0). The pooled rate of rebleeding with SEMS was 19.4 % (95 % CI 11.9-30.4, I (2) = 32) and with TIPS was 8.8 % (95 % CI 4.8-15.7, I (2) = 40). Conclusion Use of SEMS in refractory EV hemorrhage demonstrates acceptable immediate bleeding control with good technical success rate. Mortality and rebleeding rates were lesser with TIPS, however, its superiority and/ or inferiority cannot be validated due to limitations in the comparison methodology.

Abstract

BACKGROUND AND AIMS Diagnosis of gastrointestinal (GI) ulcers and/or hemorrhage by wireless capsule endoscopy (WCE) is limited by the physician-dependent, tedious, time-consuming process of image and/ or video classification. Computer-aided diagnosis (CAD) by convolutional neural networks (CNN) based machine learning may help reduce this burden. Our aim was to conduct a meta-analysis and appraise the reported data. METHODS Multiple databases were searched (from inception to November 2019) and studies that reported on the performance of CNN in the diagnosis of GI ulcerations and/ or hemorrhage on WCE were selected. Random effects model was used to calculate the pooled rates. In cases where multiple 2X2 contingency tables were provided for different thresholds, we assumed the data tables as independent from each other. Heterogeneity was assessed by I(2)% and 95% prediction intervals. RESULTS Nine studies were included in our final analysis that evaluated the performance of CNN based CAD of GI ulcers and/ or hemorrhage by WCE. The pooled accuracy was 95.4% (95% CI, 94.3-96.3), sensitivity was 95.5% (95% CI, 94-96.5), specificity was 95.8% (95% CI, 94.7-96.6), positive predictive value was 95.8% (95% CI, 90.5-98.2) and negative predictive value was 96.8% (95% CI, 94.9-98.1). I(2)% heterogeneity was negligible except for the pooled positive predictive value. CONCLUSIONS Based on our meta-analysis, CNN based CAD of GI ulcerations and/ or hemorrhage on WCE achieves high-level performance. The quality of evidence is robust and therefore CNN based CAD has the potential to become the first-choice of machine learning to optimize WCE image/video reading.