Introduction

Adhesive small bowel obstruction (ASBO) constitutes one of the most common causes of emergency room admissions worldwide. Although open adhesiolysis (OA) has long been the most widely adopted surgical approach, laparoscopic adhesiolysis (LA) is gaining momentum. However, current evidence remains controversial, as most of the studies suffer from a high risk of bias. This study aims to elucidate the comparative clinical outcomes and safety profiles of LA and OA in ASBO.

Aims & Methods

A systematic search of Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Scielo databases was performed to identify eligible studies that compared LA and OA for ASBO published up until March 2023. Only randomized controlled trials (RCTs) and matched observational studies were included. The primary outcomes encompassed duration of surgery, postoperative complications, mortality, and postoperative hospital stay. We used random-effects models for data pooling. Heterogeneity amidst studies was evaluated via the I2 statistic.

Results

From 1955 articles screened, six studies evaluating a total of 1053 patients (mean age: 65 years; 67% females) fulfilled the selection criteria and were included. From these patients, 39% had an ASA classification ≥3 (95% CI 23%-57%. I2: 96%), 21% had two or more previous abdominal surgeries (95% CI 6%-42%. I2: 94%), 8% had evidence of irreversible bowel ischemia detected at surgery (95% CI 5%-12%. I2: 31%) and 48% (n=507) underwent laparoscopic lysis of adhesions. No significant differences regarding surgery duration (MD -5.52; 95% CI -15.98, 4.94. I2: 50%), iatrogenic bowel injury (OR 1.20; 95% CI 0.56, 2.55. I2: 0%), mortality (OR 1.30; 95% CI 0.46, 3.68. I2:0%), and the development of any postoperative complication (OR 2.61; 95% CI 0.19, 36.34. I2: 91.7%) were observed. However, LA was associated with a reduced postoperative stay compared to the open approach (MD -2.40; 95% CI -3.26, -1.54. I2: 12%).
Figure. Forest plot of postoperative hospital stay (days)

Conclusion

Although OA remains the standard procedure for the treatment of ASBO, LA appears to be a feasible approach to treat this condition in selected populations, with comparable results in terms of postoperative complications and mortality, while being associated with a significantly reduced postoperative length of stay. Additional RCTs with robust methodology should be performed in order to confirm these findings.

Disclosure

The authors have nothing to disclose.

Introduction

Over the past decade, endoscopic retrograde appendicitis therapy (ERAT) has emerged as a novel, minimally invasive treatment option for patients with acute uncomplicated appendicitis (AUA). However, it is not yet known whether ERAT is a feasible alternative to antibiotic therapy (ABT).

Aims & Methods

This study aims to evaluate the efficacy of ERAT versus ABT in patients with AUA. We performed a systematic review across PubMed, Embase, and Cochrane CENTRAL databases, searching for studies comparing ERAT to ABT in this population. Outcomes of interest included therapeutic success, — defined as the absence of reintervention up to 1 year of follow-up — recurrence rates, mean time to disease recurrence, and length of hospital stay (LOS). Risk ratios (RR) were used to evaluate binary outcomes with their corresponding 95% confidence intervals (CI), while the mean difference (MD) was calculated for continuous outcomes. All statistical analyses were performed using R software (version 4.4.1) with a random-effects model.

Results

This meta-analysis included 3 studies — 2 control-matched cohorts and 1 randomized trial — comparing 457 ERAT patients to 784 patients receiving ABT for AUA. Baseline clinical characteristics were equally distributed between the groups and the time of follow-up ranged from 3 to 12 months. There was no statistically significant difference between ERAT and ABT in treatment success (RR 1.06; 95% CI 1.00 to 1.12; p = 0.07) or recurrence rate (RR 0.36; 95% CI 0.11 to 1.22; p = 0.10). The difference in time to recurrence was also not significant (MD 116 days; 95% CI -49 to 282; p = 0.17). However, ERAT was associated with a significantly shorter LOS (MD -1.85 days; 95% CI -3.15 to -0.55; p = 0.005).

Conclusion

In patients with acute uncomplicated appendicitis, ERAT is non-inferior to antibiotic therapy, while considerably reducing the length of hospital stay. Further studies are warranted to better assess the efficacy of ERAT compared to ABT, and whether it decreases the risk of appendicitis recurrence.

References

1. Kang, J., et al. (2021). The modified endoscopic retrograde appendicitis therapy versus antibiotic therapy alone for acute uncomplicated appendicitis in children. Surgical Endoscopy, 35(11), pp.6291-6299. Available at: https://doi.org/10.1007/s00464-020-08129-8.
2. Li, D., et al. (2023). Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. British Journal of Surgery, 110(6), pp.635-637. Available at: https://doi.org/10.1093/bjs/znad023.
3. Zhan, K., et al. (2024). Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. The American Journal of Gastroenterology. Available at: https://doi.org/10.14309/ajg.0000000000003118.
   

Introduction

Irritable bowel syndrome (IBS) is among the most prevalent gastrointestinal conditions. However, its therapeutic management poses challenges, with many current recommendations resting on a low level of evidence.

Aims & Methods

Our objective is to conduct a systematic review with meta-analysis of randomized, double-blind, placebo-controlled trials to assess the efficacy of antidepressants in treating IBS. ​
Systematic review with meta-analysis performed according to PRISMA guidelines and registered on the PROSPERO platform (CRD42024502427). PubMed, EMBASE, and The Cochrane Library platforms were searched from inception to January 2024. Only randomized, double-blind, placebo-controlled trials, conducted in patients with IBS patients, with a minimum treatment period of 4 weeks, were included. The quality of evidence was assessed using the revised version of the Cochrane tool (RoB 2). A random-effects model was used. Heterogeneity was assessed by the I² statistics. Funnel plots and the Egger test were used to assess publication bias. Statistical analysis was performed using STATA v16.

Results

The search strategy identified 1340 studies, of which 16 were included, totaling 1428 patients. Among these studies, 733 patients were assigned to the antidepressant group and 698 to the placebo group. In the intervention group, 405 (55.3%) patients reported improvement, compared to only 227 (32.5%) patients in the placebo group. The meta-analysis showed that the use of antidepressants in patients with IBS provides a benefit in overall symptom improvement (OR=3.02; 95% CI 2.16-4.2) compared to placebo.
A subgroup analysis of 9 studies, comprising 1008 patients, assessed the efficacy of tricyclic antidepressants (TCAs) in the same setting and revealed similar results (OR=3.39, 95% CI 2.24-5.12), as did the sub-analysis of 6 studies (including 363 patients) evaluating the efficacy of selective serotonin reuptake inhibitors (SSRIs) (OR= OR=2.39, 95% CI 1.14-5.01). The efficacy also extends to patients refractory to first-line measures (6 studies including 713 patients) (OR=2.96, 95% CI 1.67-5.25) and to patients without psychopathology (8 studies including 471 patients) (OR=2.92, 95% CI 1.6-5.31). Concerning symptoms, a sub analysis also confirmed the efficacy of antidepressants specifically both in the improvement of abdominal pain (OR=4.33, 95% CI 2.1-8.93) and in abdominal distension (OR=2.68, 95% CI 1.42-5.04).
Only in the sub-analysis assessing the efficacy of SSRIs and of the improvement of abdominal pain, I² was slightly >60%, indicating substantial heterogeneity, but <75%. Causes of heterogeneity were searched. Publication bias was detected, and potential sources were identified. Sub-analysis without the studies identified as sources of this bias revealed similar results with lower heterogeneity.

Conclusion

Antidepressants, including both TCAs and SSRIs, demonstrate efficacy in patients with IBS, presenting a validated treatment option supported by evidence. Moreover, these medications can be beneficial to patients resistant to initial treatments and those lacking psychopathological symptoms.

References

Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut−Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018;154:1140-1171.e1. https://doi.org/10.1053/j.gastro.2017.11.279.
Lacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD, et al. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol 2021;116:17–44. https://doi.org/10.14309/ajg.0000000000001036.
Lovell RM, Ford AC. Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis. Clin Gastroenterol Hepatol 2012;10:712-721.e4. https://doi.org/10.1016/j.cgh.2012.02.029.
Vasant DH, Paine PA, Black CJ, Houghton LA, Everitt HA, Corsetti M, et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut 2021;70:1214–40. https://doi.org/10.1136/gutjnl-2021-324598.

Disclosure

FP received speaker fees from Abbvie, Falk, Ferring, Janssen, Pfizer, Pharmakern, Takeda and Tillotts. The other authors have no conflict of interest.

Introduction

Despite the availability of various image-enhanced endoscopy (IEE) techniques, direct comparisons of their performance in detecting lower gastrointestinal lesions are scare.

Aims & Methods

This systematic review and network meta-analysis aims to compare the diagnostic performance of different IEE modalities on detection of colorectal lesions. We conducted a systematic search of PubMed, EMBASE, and Web of Science for randomized controlled trials (RCTs) published up to January 1, 2025, which compared the diagnostic accuracy of various IEE in detecting colorectal lesions. The primary outcomes were rate-based metrics including polyp (PDR), adenoma (ADR), advanced adenoma (AADR), and serrated lesion detection rate (SLDR). Additionally, count-based measures were compared, including mean polyp per patient (MPP) and mean adenoma per patient (MAP). Narrow-band imaging (NBI) techniques were classified into two categories: old generation (e.g., EVIS LUCERA Spectrum or EXERA II) and new generation (e.g., EVIS EXERA III or LUCERA ELITE). To rank the performance of each modality, we employed the Surface Under the Cumulative Ranking curve (SUCRA). For binary outcomes, odds ratios (ORs) were calculated; and for continuous outcomes, mean differences (Δ) were determined with all results reported alongside their respective 95% confidence intervals (CIs).

Results

IEE modalities(PDR)	SURCA	Probaility of being the best	Mean Rank
CE	92.6	55.8	1.6
TXI	79.2	34.7	2.7
LCI	60.5	0.8	4.2
NBI(New generation)	60.2	2.1	4.2
IEE modalities(ADR)	SURCA	Probability of being the best	Mean Rank
TXI	96.9	89.3	1.2
LCI	79.7	6.7	2.4
CE	55.4	1.5	4.1
NBI(New generation)	48	0.5	4.6

A total of 45 RCTs involving 55,165 participants were included. Linked color imaging (LCI) and new-generation NBI were the most frequently evaluated IEE modalities. For PDR, the highest SUCRA are seen with chromoendoscopy (CE, 92.6), texture and color enhancement imaging (TXI, 79.2), and LCI (60.5). For ADR, TXI showed the best performance (SUCRA: 95.9), followed by LCI (79.7) and CE (55.4). In advanced adenoma detection, TXI (76.4) and CE (69.4) performed best. Compared to white light imaging (WLI), LCI (Δ: 0.71, 95% CI: 0.55–0.92) and TXI (Δ: 0.58, 95% CI: 0.34–0.96) significantly increased PDR. CE was the only technique significantly superior to WLI in both ADR (Δ: 0.80, 95% CI: 0.64–0.99) and AADR (Δ: 0.66, 95% CI: 0.45–0.97). For continuous outcomes, LCI (SUCRA: 75.3) and new-generation NBI (74.7) performed best for MPP; and new-generation NBI (82.1) and TXI (80.2) ranked highest for MAP. Few studies reported detection rates of serrated lesion and no significant differences were found among IEE methods due to limited data.

Conclusion

This network meta-analysis demonstrates that TXI, new-generation NBI, LCI, and CE all exhibit better performance than WLI in detecting colorectal lesions. TXI demonstrated consistent efficacy in both polyp and adenoma detection. The new-generation NBI and LCI showed significant advantages in terms of lesion yield per patient. However, the diagnostic benefit of IEE for serrated lesions remains uncertain due to insufficient evidence. Additional head-to-head studies are necessary to further confirm these findings.

Introduction

Bowel preparation is recognized as the most burdensome aspect of the whole colonoscopy procedure, sometimes even worse that the examination itself, and represents a major barrier to screening colonoscopy. Mannitol could significantly improve patient acceptability as it is rapid, requires a single dose, a low volume and has a pleasant taste. The SATISFACTION study compared oral mannitol 100g/750ml with standard split-dose 2L PEG-ASC (MoviPrep®).

Aims & Methods

The SATISFACTION Phase III study was an international, multicentre, randomized (1:1), parallel-group, endoscopist-blinded non inferiority trial. Primary endpoint was the proportion of patients with adequate bowel cleansing. Secondary endpoints concerned efficacy (adenoma detection rate, caecal intubation rate, time of evacuation), safety (intestinal gases concentration, haematobiological parameters, adverse events) and patient satisfaction. The study included 703 patients (352 treated with mannitol and 351 with PEG-ASC) undergoing elective colonoscopy.

Results

Mannitol was not inferior to PEG-ASC for proportion of patients with adequate cleansing (91.1% and 95.5% respectively; p value for the non-inferiority =0.0095). There was no significant difference for secondary efficacy endpoints. The profile of acceptability was significantly better in mannitol group for easy to use, taste, willingness to use (p<0.0001 for all parameters). The concentration of intestinal gases (H₂, CH₄) was similar in the two groups and well below those potentially critical.

Conclusion

Mannitol was not inferior to PEG-ASC for proportion of patients with adequate cleansing (91.1% and 95.5% respectively; p value for the non-inferiority =0.0095). There was no significant difference for secondary efficacy endpoints. The profile of acceptability was significantly better in mannitol group for easy to use, taste, willingness to use (p<0.0001 for all parameters). The concentration of intestinal gases (H₂, CH₄) was similar in the two groups and well below those potentially critical.

Disclosure

Prof. Gian Eugenio Tontini and Prof. Maurizio Vecchi received a consultant fee from NTC Pharma. Anna Orsatti is a current NTC Pharma employee

Introduction

Colonoscopy techniques is an independent factor of adenoma detection rate. However, the colonoscope insertion methods and cecal intubation time is often ignored compared with relevant technology or colonoscopy performance indicator in withdrawal stage. The effect of water exchange (WE) method characterized by water infusion with water removal primarily during insertion stage on colonoscopy has remained controversial. We aimed to carry out a meta-analysis to systematically evaluate the relationship between WE and quality of colonoscopy compared with the conventional methods include air insufflation and carbon dioxide insufflation.

Aims & Methods

Aims: To evaluate the effect of water exchange method versus conventional methods including air insufflation and carbon dioxide insufflation method for the quality of colonoscopy.
Methods: ​We searched randomized controlled trials published up to October 2022 from PubMed, Web of Science, the Cochrane Library, CNKI, Wanfang, SinoMed databases. Two reviewers independently searched the literatures based on standards to extract the data and evaluate the quality. The primary outcomes were cecal intubation time and adenoma detection rate. The secondary outcomes included cecal intubation rate, quality of bowel preparation, pain score, number of abdominal compression, number of position change. Meta-analysis was conducted by RevMan5.4.1.The study protocol was registered in PROSPERO (CD42022327954).

Results

A total of 23 studies involving 10654 patients were included. Although cecal intubation time was prolonged in WE (MD=1.81, 95%CI: 1.28, 2.35; P < 0.001), WE had higher adenoma detection rate (OR=1.40，95%CI：1.26, 1.55；P<0.001), cecal intubation rate (OR=1.62；95%CI：1.24,2.10；P<0.001) and quality of bowel preparation (MD=0.61；95%CI：0.42, 0.79；P<0.001) compared with conventional colonoscopy. In addition, WE had significantly lower pain sores (MD=-1.07；95%CI：-1.39,-0.76；P<0.001), number of abdominal compression (OR=0.42；95%CI：0.29,0.60；P<0.001) and number of position change (OR=0.59；95%CI：0.42,0.82；P=0.002) than conventional colonoscopy.

Conclusion

Despite WE colonoscopy prolonged cecal intubation time, it could significantly increase adenoma detection rate, cecal intubation rate and quality of bowel preparation. And beyond that, WE reduced patient pain, the proportion of abdominal compression and position change. WE is a better choice for high-quality colonoscopy.

Introduction

Diverticular disease of the colon is one of the most common diseases in Western world. Despite in the natural history in most of cases diverticulosis remains asymptomatic or manifests with mild abdominal pain, complications may occur. Bleeding from diverticula is one of the most common complications and, despite it is usually a self-limiting event, it may lead to anemia or shock. Among the endoscopic interventions for active bleeding, direct or indirect clipping of the diverticulum is the most diffuse one. However, it has been hypothesized that endoscopic band ligation (EBL) may be more effective, since it may improve the chance to close the bleeding vessel, with a better outcome on long term. Therefore we performed a meta-analysis comparing clipping versus EBL for diverticular bleeding.

Aims & Methods

Literature search on main databases (PubMed, Web of science, SCOPUS, EMBASE) was performed in November 2022. Studies comparing clip versus EBL for acute diverticular bleeding were selected. We excluded case series, abstract and articles not written in English. The following outcomes were analysed: short term effectiveness, early rebleeding, tardive rebleeding and need for surgery or radiologic embolization. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculate according to Mantel-Haenszel method. Heterogeneity was estimated by I² statistic with chi square test, and, if present, a random effect model was used, otherwise a fixed one was adopted.

Results

Seven studies were selected, overall enrolling 2322 patients (979 in EBL and 1343 in clip groups). Immediate haemostasis was achieved in the EBL and clipping group respectively in the 96.8% and 96.5% (OR=0.94, 95% CI 0.59-4.19, p=0.79). Early rebleeding was observed more frequently in the clipping (25.0%) than in the EBL group (11.8%), with an OR=0.40 (95% CI 0.32-0.51, p<0.001). Similarly, tardive rebleeding was more common in the clipping arm (37.4%) than in the EBL (24.5%), OR=0.39, 95% CI 0.22-0.68, p=0.0001. Patients receiving clipping needed more frequently salvage surgery or embolization than EBL (1.48% versus 0.53%, OR=0.40, 95% CI 0.17-0.93, p=0.03).

Conclusion

Despite EBL and clip have similar effectiveness in achieving immediate haemostasis, EBL showed better effectiveness in maintaining it on longer interval times, with less probable need for major surgical/radiologic interventions.