Abstract

BACKGROUND AND AIMS Upper gastro-intestinal bleeding is a common condition associated with significant morbidity and mortality. Endoscopic hemostasis remains the mainstay of therapy and is mainly aimed at effective hemostasis and prevention of rebleeding. Lesions with high-risk stigmata can have rebleeding rates of as high as 26.3%. Rebleeding is associated with increased mortality and reduced success rates of endoscopic retreatment. The over-the-scope-clip (OTSC) is a device with widespread endoscopic indications including hemostasis for non-variceal upper GIB (NVUGIB). The current study presents a systematic review and meta-analysis comparing OTSC versus standard therapy (STD) for NVUGIB. METHODS Multiple databases were searched through April 2022 for studies comparing OTSC and standard therapy for NVUGIBs. The primary outcomes were clinical success rates, rebleeding rates, procedure times and secondary outcomes were mortality rates and length of hospitalization. Meta-analysis was performed to determine pooled odds ratios (ORs) to compare outcomes between the OTSC and standard therapy groups. RESULTS Ten studies, including four randomized controlled trials, with 914 patients were included in the final analysis. 431 patients with NVUGIB's were treated with OTSC and 483 patients were treated with STD. Patients treated with OTSC had an overall lower risk of 7-day (RR 0.41 (95% CI 0.24-0.68, I(2) = 0%)) and 30-day rebleeding (RR 0.46 (95% CI 0.31-0.65, I(2) = 0%)). Clinical success rates were higher with OTSC compared with STD (RR 1.36 (95% CI 1.06 - 1.75. Mean procedure time was shorter in the OTSC group by 6.62 min (95% CI 2.58 - 10.67) vs STD therapy. I(2) = 84%. There was no statistically significant difference in terms of mortality between the OTSC and STD groups, RR 0.55 (95% CI 0.24-1.24, I(2) = 0%). Length of hospitalization was comparable between both groups with the pooled mean difference for OTSC vs STD being 0.87 d (-1.62 d - 3.36 d, I(2) = 71%). CONCLUSIONS While our study is limited to high-risk NVUGIB's, our analysis shows that hemostasis with OTSC is associated with a lower 7-day and 30-day rebleeding rate, higher clinical success rates and shorter procedure time with similar mortality rates and length of hospital stay as compared to standard therapy.

Abstract

Background and study aims  There is limited evidence on the effectiveness of hemostatic powders in the management of lower gastrointestinal bleeding (LGIB). We aimed to provide a pooled estimate of their effectiveness and safety based on the current literature. Patients and methods  Literature review was based on computerized bibliographic search of the main databases through to December 2020. Immediate hemostasis, rebleeding rate, adverse events, and mortality were the outcomes of the analysis. Pooled effects were calculated using a random-effects model. Results  A total of 9 studies with 194 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95 % of patients (95 % confidence interval [CI] 91.6 %-98.5 %), with no difference based on treatment strategy or bleeding etiology. Pooled 7- and 30-day rebleeding rates were 10.9 % (95 %CI 4.2 %-17.6 %) and 14.3 % (95 %CI 7.3 %-21.2 %), respectively. Need for embolization and surgery were 1.7 % (95 %CI 0 %-3.5 %) and 2.4 % (95 %CI 0.3 %-4.6 %), respectively. Overall, two patients (1.9 %, 95 %CI 0 %-3.8 %) experienced mild abdominal pain after powder application, and three bleeding-related deaths (2.3 %, 95 %CI 0.2 %-4.3 %) were registered in the included studies. Conclusion  Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.

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.