Introduction

Variceal bleeding is a common and life-threatening complication of liver cirrhosis, with endoscopic therapy being an important treatment modality [1]. There are several endoscopic techniques available for the management of variceal bleeding, including band ligation, sclerotherapy, tissue adhesives, and endoscopic ultrasound-guided variceal obturation (EUS-VO) [2].

Aims & Methods

This meta-analysis aimed to compare the efficacy and safety of different endoscopic modalities for the prevention and management of variceal bleeding in patients with liver cirrhosis. A systematic literature search was conducted in several databases, including PubMed, Embase, and Cochrane Library, from inception to September 2022. Randomized controlled trials, cohort studies, and case-control studies that compared different endoscopic modalities for the management of variceal bleeding in patients with liver cirrhosis were included. The primary outcomes of interest were initial hemostasis rates, rebleeding rates, and adverse events.

Results

A total of 15 studies (n = 1,742) met the inclusion criteria and were included in the meta-analysis. The pooled results showed that band ligation was associated with lower rebleeding rates compared to sclerotherapy (OR 0.59, 95% CI 0.44-0.79, p = 0.001), while sclerotherapy was associated with a higher risk of adverse events (OR 3.21, 95% CI 1.69-6.11, p < 0.001). Tissue adhesives, such as N-butyl-2-cyanoacrylate, were associated with higher initial hemostasis rates compared to other endoscopic therapies (OR 1.82, 95% CI 1.30-2.55, p = 0.001) and lower rebleeding rates (OR 0.39, 95% CI 0.20-0.77, p = 0.006). EUS-VO was associated with higher initial hemostasis rates (OR 1.93, 95% CI 1.08-3.43, p = 0.027) and lower rebleeding rates (OR 0.43, 95% CI 0.26-0.71, p = 0.001) compared to traditional endoscopic therapies.

Conclusion

Our meta-analysis suggests that band ligation and tissue adhesives may be superior to sclerotherapy for the prevention and management of variceal bleeding in patients with liver cirrhosis. EUS-VO may be a promising alternative to traditional endoscopic therapies, although further studies are needed to confirm its efficacy and safety. The choice of endoscopic technique should be individualized based on patient factors and physician expertise.

References

1-Tang L, Li X, Cui J, Huang LY. EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts. Endosc Ultrasound. 2023 Jan-Feb;12(1):84-89. doi: 10.4103/EUS-D-22-00006. PMID: 36510864.
2-Huang Z, Zhang W, Lv F, Ma L, Xiao Y, Gao S, Zhang M, Wang Y, Li P, Zhao H, Yu H, Cao J, Ke G, Wang Y, Chen M. Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study. Endosc Ultrasound. 2023 Jan-Feb;12(1):74-83. doi: 10.4103/EUS-D-21-00260. PMID: 36510863.

Introduction

Variceal bleeding accounts for approximately 20–30% of cirrhosis-related deaths and remains a major complication of portal hypertension in patients with liver cirrhosis (1). The National Institute for Health and Care Excellence (NICE) in the United Kingdom (UK) recommends the administration of propranolol or carvedilol, or endoscopic variceal ligation (EVL) as primary prevention of medium to large oesophageal varices. (2). However, the comparative efficacy and safety profiles of these approaches remain unclear.

Aims & Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Electronic databases were searched to identify randomised controlled trials (RCTs) comparing EVL and propranolol for the primary prevention of variceal bleeding in patients with liver cirrhosis. Primary outcomes included incidence of variceal bleeding, all-cause mortality, and bleeding-related mortality. Secondary outcomes included adverse effects related to prophylactic treatment. Data were pooled using fixed or random-effects models depending on heterogeneity.

Results

Nine RCTs comprising a total of 916 patients were included. EVL was associated with a significantly lower risk of variceal bleeding compared to propranolol (odds ratio [OR] 0.44; 95% confidence interval [CI]: 0.28–0.67; p = 0.0002) and reduced bleeding-related mortality (OR 0.57; 95% CI: 0.33–0.99; p = 0.05). Adverse effects were also significantly less frequent in the EVL group (OR 0.46; 95% CI: 0.32–0.67; p < 0.0001). No statistically significant difference was found in all-cause mortality between the two interventions (OR 0.93; 95% CI: 0.63–1.37; p = 0.72).

Conclusion

EVL is more effective than propranolol for the primary prevention of variceal bleeding in patients with cirrhosis, demonstrating lower rates of first variceal bleed, bleeding-related mortality, and treatment-related adverse events. Although no difference in all-cause mortality was observed, the findings support the consideration of EVL as a first-line prophylactic option. Further well-designed, multicentre RCTs with standardised outcomes, extended follow-up, and robust cost-effectiveness analyses are essential to optimise clinical decision-making and support personalised treatment strategies.

References

1. García-Tsao G, Bosch J. Varices and variceal hemorrhage in cirrhosis: A new view of an old problem. Clin Gastroenterol Hepatol. 2015;13(12):2109–2117.
2. National Institute for Health and Care Excellence (NICE). Cirrhosis in over 16s: assessment and management. NICE guideline [NG50]. 2016. Available at: https://www.nice.org.uk/guidance/ng50

Introduction

Endoscopic hemostasis is first-line therapy in managing peptic ulcer bleeding (PUB) with high-risk stigmata (Forrest classification Ia, Ib, IIa). While argon plasma coagulation (APC) is widely available and easy to use, there are limited studies with a limited number of patients evaluating its efficacy in PUB. This meta-analysis evaluates the effectiveness of APC in high risk PUB in achieving initial hemostasis and preventing rebleeding.

Aims & Methods

We performed a systematic literature search of PubMed, Embase, Web of Science, and Scopus to identify studies up to October 2024, evaluating APC versus alternative endoscopic hemostasis modalities for high-risk PUB. Eligible studies included those reporting on initial hemostasis and rebleeding outcomes. Two reviewers (KS, MO) independently screened studies and extracted data, resolving discrepancies by consensus. Quality assessments were conducted using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using a random-effects model to account for study heterogeneity, quantified by I^2 statistics.

Results

Fourteen studies met inclusion criteria (7 observational and 7 RCTs), with pooled sample sizes of n=816 and n=975 respectively. Meta-analysis of all studies showed that for the outcome of initial hemostasis, the pooled OR was 1.01 (95% CI: 0.39–2.62, p = 0.976), demonstrating no significant difference between APC and other endoscopic treatments. Similarly, rebleeding rates showed no significant difference (pooled OR: 1.12; 95% CI: 0.69–1.83, p = 0.636). When we limited our meta-analysis to only the 6 RCTs with an active hemostasis treatment control group, we again found similar results for both outcomes of initial hemostasis and rebleeding.

Conclusion

APC appears comparable and non-inferior to other standard of care endoscopic hemostasis modalities in achieving initial hemostasis and preventing rebleeding in high-risk PUB. Updated guidelines will need to re-evaluate and decide where APC fits in with endoscopic hemostasis of high-risk PUB.

References

Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019;171(11):805-22.
Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021;53(3):300-32

Disclosure

Ian Gralnek. has received lecture fees from Astra-Zeneca, Taro Pharma, Vifor Pharma and 3D Matrix. He is also a paid consultant for Boston Scientific, GI View, Motus GI and Symbionix and is a member of the medical advisory board of Motus GI

Introduction

Managing tumoral bleeding poses a significant challenge for endoscopists. Traditional tools such as clips and heat-probes frequently prove inadequate in controlling stubborn bleeding caused by mucosal invasion from these tumors. Hemostatic powder sprays provide a novel solution by applying a combination of minerals and polymers directly onto the tumor surface, forming a mechanical barrier to seal the bleeding site. However, there is a scarcity of data regarding their effectiveness in treating hemorrhagic gastrointestinal neoplasms. This study seeks to evaluate the efficacy of Hemostatic powder spray in patients suffering from gastrointestinal bleeding related to malignancies.

Aims & Methods

This study aimed to evaluate the effectiveness of Hemostatic powder spray compared to standard clinical treatment in controlling gastrointestinal bleeding originating from malignant lesions. The primary outcome measures included the combined rates of rebleeding within 30 days, while secondary outcomes encompassed the combined rates of mortality over any time period.
We gathered relevant data, an extensive search of electronic databases was conducted up to April 2024. Only randomized controlled trials (RCTs) were included in the study, focusing specifically on cases where Hemostatic powder spray was pitted against conventional endoscopic techniques for managing bleeding caused by gastrointestinal tumors.

Results

Three studies involving a total of 162 patients were included in this meta-analysis. Among them, 83 patients underwent treatment with Hemostatic spray powder alone, while 79 patients received conventional hemostatic techniques. The pooled results of the analysis revealed that Hemostatic powder spray was associated with a lower incidence of re-bleeding beyond 30 days from the onset of treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.15-0.84), demonstrating a significant advantage over standard endoscopy in the management of gastrointestinal tumor bleeding (p-value 0.01). Additionally, there was no significant difference observed in all-time mortality between the two treatment groups (OR 0.40, 95% CI 0.19-0.83, p-value 0.09).

Conclusion

Hemostatic spray powders demonstrate significant efficacy in achieving hemostasis for gastrointestinal bleeding associated with malignancies. They should be regarded as a viable alternative to conventional endoscopic methods in such cases. Subsequent research should be structured to assess both the effectiveness and safety of hemostatic spray powders as a primary hemostatic approach compared to traditional endoscopic techniques.

References

1. Pittayanon, Rapat et al. “The efficacy of Hemospray in patients with upper gastrointestinal bleeding from tumor.” Endoscopy international open vol. 4,9 (2016): E933-6. doi:10.1055/s-0042-109863
2. Chen YI, Wyse J, Lu Y, et al. TC-325 hemostatic powder versus current standard of care in managing malignant GI bleeding: a pilot randomized clinical trial. Gastrointest Endosc 2020;91:321–328.
3. Bruno da Costa Martins, et al. Mo1140. Preliminary results of a randomized controlled trial comparing hemostatic powder versus optimal clinical treatment in the management of gastrointestinal bleeding from malignancy, Gastrointestinal Endoscopy, Volume 87, Issue 6, Supplement, 2018, Pages AB415-AB416, ISSN 0016-5107.
4. Martins BC, Abnader Machado A, Scomparin RC, et al. TC-325 hemostatic powder in the management of upper gastrointestinal malignant bleeding: a randomized controlled trial. Endosc Int Open 2022;10:E1350–E1357.
5. Minhem MA, Nakshabandi A, Mirza R, et al. Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: anatomical prevalence, predictors, and interventions. World J Gastrointest Endosc 2021; 13:391–406.
6. Hussein, Mohamed et al. “Hemostatic powder TC-325 treatment of malignancy-related upper gastrointestinal bleeds: International registry outcomes.” Journal of gastroenterology and hepatology vol. 36,11 (2021): 3027-3032. doi:10.1111/jgh.15579

Introduction

Mediastinal lesions develop from structures located in the mediastinal compartments and the paravertebral areas. The diagnosis of these lesions is primarily based on imaging studies such as computed tomography and magnetic resonance imaging, which confirm the presence of the lesions and suspected metastatic disease

Aims & Methods

This study aims to assess the factors that determine the diagnostic accuracy and yield of endoscopic ultrasound (EUS) in diagnosing mediastinal lesions. This multicenter study involved a list of centres providing EUS services across ten countries all over the globe. The appropriate information was collected regarding EUS-FNA and EUS-FNB procedures, including nature of the lesion, needle types, needle passes, and complications of the techniques. The frequency/percentage conveyed data on the qualitative variables. The p-values were obtained using the Chi-square two-tailed exact test. The significance of the analysis was defined as p<0.05. All the syntheses were performed using the Statistical Package for the Social Sciences (SPSS version 27; SPSS Inc., Chicago, IL).

Results

A total of 439 participants were involved in this study, 255 (58.1%) males and 184 (41.9%) females, with a mean age of 55.7314.93 years. The average accuracy from the valid matched cases between EUS, cytopathy, and final diagnosis (300 out of 331) was 90.63%. EUS-FNA and EUS-FNB diagnostic yield was influenced by needle types, needle size, number of needle passes, and lesion size. Needles with smaller diameters (22G) offered greater diagnostic yield than needles with larger diameters (19G). However, the diagnostic matching accuracy of EUS in relation to needle sizes was statistically insignificant (p= 0.774). A minimal number of needle passes (between 2 and 4) showed a higher diagnostic yield than a higher number of needle passes (>5) with more diagnostic matching accuracy (p = 0.009). EUS-FNB accounted for a 0.5% complication incidence rate each for fever, pain, thoracic pain, and hemorrhage. Patients undergoing EUS-FNA, EUS-FNB, or both procedural examinations had no significant complications (p = 0.085) Table 1.

Table 1: Incidence rate of complications associated with EUS examination techniques

Conclusion

The diagnostic yield of EUS procedures is affected by needle types, number of needle passes, lesion size, and needle size. Besides, EUS-FNA and EUS-FNB are infrequently associated with serious complications, these techniques are safe and offer higher diagnostic yield when utilised responsibly by endosonographers.

References

1- Gadour E, Awad A, Hassan Z, Shrwani KJ, Miutescu B, Okasha HH. Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis. World J Gastroenterol. 2024 Feb 21;30(7):742-758. doi: 10.3748/wjg.v30.i7.742. PMID: 38515947; PMCID: PMC10950627.
2- Okasha HH, El-Meligui A, Pawlak KM, Żorniak M, Atalla H, Abou-Elmagd A, Abou-Elenen S, El-Husseiny R, Alzamzamy A. Practical approach to linear EUS examination of the mediastinum. Endosc Ultrasound. 2021 Nov-Dec;10(6):406-413. doi: 10.4103/EUS-D-21-00019. PMID: 34854401; PMCID: PMC8785678.

Introduction

Gastric outlet obstruction (GOO) is a debilitating condition commonly caused by malignant or benign diseases, impairing gastric emptying and nutritional status. While surgical gastrojejunostomy (SGJ) has traditionally been the standard palliative approach, endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a minimally invasive alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ versus SGJ for the management of GOO.

Aims & Methods

A systematic search of PubMed, Embase, Medline, and Cochrane Library was conducted to identify studies directly comparing EUSGJ and SGJ in adult patients with GOO. Nine retrospective studies comprising 1,086 patients (654 EUSGJ; 432 SGJ) were included. Primary outcomes included technical and clinical success, length of hospital stay (LOS), operative time, and overall complication rates. Secondary outcomes included infection, ileus, hemorrhage, perforation, and re-intervention. Meta-analyses were performed using fixed or random effects models depending on data heterogeneity.

Results

EUSGJ was significantly superior to SGJ in terms of technical success (OR = 0.16; 95% CI: 0.05–0.45; p = 0.0006), shorter operative time (MD = –96.89 minutes; 95% CI: –146.16 to –47.61; p < 0.00001), reduced postoperative LOS (MD = –4.79 days; 95% CI: –6.52 to –3.06; p < 0.0001), lower overall complication rates (OR = 0.24; 95% CI: 0.17–0.33; p < 0.00001), reduced postoperative ileus (OR = 0.07; 95% CI: 0.02–0.17; p < 0.00001), and fewer infections (OR = 0.17; 95% CI: 0.08–0.37; p < 0.00001). No statistically significant differences were found regarding clinical success, re-intervention, hemorrhage, or perforation.

Conclusion

EUSGJ demonstrates superior procedural outcomes and safety profiles compared to SGJ in the management of GOO and represents a valuable tool in expert hands. However, further prospective studies and randomized trials are necessary to validate these findings, assess long-term outcomes, and define its role within individualized patient care and clinical guidelines.

Disclosure

No conflict of interest