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Endoscopic transoral outlet reduction (TORe) has been used to manage weight regain after Roux-en-Y gastric bypass. We conducted a meta-analysis to summarize the efficacy and safety of the two most commonly used techniques: full-thickness suturing plus argon plasma mucosal coagulation (ft-TORe) and argon plasma mucosal coagulation alone (APMC-TORe). A literature search of publication databases was performed from their inception to February 2020 for relevant studies. The outcomes of interest were percentage total body weight loss, gastrojejunal anastomosis (GJA) diameter, and adverse events (AEs). The pooled effect estimates were analyzed using a random-effects model. Meta-regression was conducted to identify associations between GJA diameter and weight loss. Nine ft-TORe (n = 737) and 7 APMC-TORe (n = 888) studies were included. APMC-TORe was performed as a series of sessions (mean number of sessions ranging from 1.2 to 3), whereas ft-TORe was mostly performed as a single session. Percentage total body weight loss was 8.0% (95% confidence interval [CI], 6.3%-9.7%), 9.5% (95% CI, 8.1%-11.0%), and 5.8% (95% CI, 4.3%-7.1%) after ft-TORe and 9.0% (95% CI, 4.1%-13.9%), 10.2% (95% CI, 8.4%-12.1%), and 9.5% (95% CI, 5.7%-13.2%) after APMC-TORe at 3, 6, and 12 months, respectively, with no weight-loss difference at 3 and 6 months (P >.05). Only one severe AE was observed after APMC-TORe and none after ft-TORe. Stricture formation was the most common AE (ft-TORe 3.3% and APMC-TORe 4.8%, P =.38). All were successfully treated by endoscopic dilation or conservative treatment. Smaller aperture of the post-TORe GJA and greater change in the GJA diameter correlated with greater weight loss in APMC-TORe and numerical trends in ft-TORe. This meta-analysis demonstrates that both ft-TORe and APMC-TORe offer significant and comparable weight-loss outcomes with a high and comparable safety profile. However, APMC-TORe typically required multiple endoscopic sessions. Identifying a goal for the final and change in GJA diameter could be useful treatment targets. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Association Between Cholecystectomy and Nonalcoholic Fatty Liver Disease: A Meta-analysis."

A letter to the editor in response to the article "Association between Helicobacter pylori infection and osteoporosis: A systematic review and meta-analysis," that was publihsed in a previous issue of the journal is presented.

Background and Aim Diverticular disease and colorectal neoplasia are common digestive disorders worldwide. Both diseases share epidemiological trends and certain risk factors including advancing age, physical inactivity, and Western diet and lifestyle. Studies assessing the association between these diseases reported inconsistent results. Thus, we conducted a systematic review and meta-analysis to determine the association between diverticular disease and colorectal adenomas, advanced adenomas and cancer. Methods A comprehensive search of the databases MEDLINE and EMBASE was done from inception through March 2016. Inclusion criterion was the observational studies' assessment of the association between diverticular disease and colorectal neoplasia in adult participants. Pooled OR and 95% confidence interval (CI) were calculated using a random effect. Results Data were extracted from 14 observational studies (11 cross-sectional studies, one case-control study and two cohort studies). Diverticular disease was associated with increased odds of adenomas (OR = 1.67, 95% CI 1.27-2.21, 10 studies), but not associated with advanced adenomas (OR = 1.19, 95% CI 0.88-1.62, I2 = 52%, four studies) or colorectal cancer (OR = 1.36, 95% CI 0.47-3.92, I2 = 98%, seven studies). Conclusions Our meta-analysis demonstrated that diverticular disease was associated with colorectal adenomas. Colonoscopists should be aware of this association and carefully examine the entire large bowel in individuals with diverticulosis. [ABSTRACT FROM AUTHOR]

Background Arterial stiffness has been observed to be an independent predictor for cardiovascular events. Effects of cholesterol lowering agents (statins) on arterial stiffness are inconsistent. We conducted a systematic review with a meta-analysis of all RCTs investigating the impact of statin therapy on arterial properties. Methods We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane from their dates of inception through April 2016. The inclusion criteria were published RCTs comparing change in arterial stiffness between statin administration and active control or placebo groups. Arterial stiffness is determined by aortic pulse wave velocity (PWV). We used a random-effects model and calculated pooled standardized mean difference (SMD) with 95% confidence intervals (CI) comparing change in PWV between the statin and control groups. Results Six studies were included in the meta-analysis. Statin therapy includes simvastatin, rosuvastatin, lovastatin, fluvastatin, and atorvastatin. Compared with the active control or placebo group, the statin therapy group had lower aPWV (SMD = 2.31, 95% CI: 1.15–3.45, P heterogeneity = 0.07, I 2 = 93%). Conclusion Our meta-analysis demonstrates that statin therapy has a beneficial effect on aortic arterial stiffness. Further studies should be conducted to assess the effects of this therapy on arterial stiffness at various sites and conditions. [ABSTRACT FROM AUTHOR]

Background: Lumen-apposing metal stents (LAMS) are an alternative therapeutic option for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluate the safety and efficacy of LAMS for the management of benign GI strictures. Methods: Consecutive patients who underwent a LAMS placement for benign luminal GI strictures at a tertiary care center between January 2014 and July 2021 were reviewed. Primary outcomes included technical success, early clinical success, and adverse events (AEs). Other outcomes included rates of stent migration and re-intervention after LAMS removal. Results: One hundred and nine patients who underwent 128 LAMS placements (67.9% female, mean age of 54.3 ± 14.2 years) were included, and 70.6% of the patients had failed prior endoscopic treatments. The majority of strictures (83.5%) were anastomotic, and the most common stricture site was the gastrojejunal anastomosis (65.9%). Technical success was achieved in 100% of procedures, while early clinical success was achieved in 98.4%. The overall stent-related AE rate was 25%. The migration rate was 27.3% (35/128). Of these, five stents were successfully repositioned endoscopically. The median stent dwell time was 119 days [interquartile range (IQR) 68–189 days], and the median follow-up duration was 668.5 days [IQR: 285.5–1441.5 days]. The re-intervention rate after LAMS removal was 58.3%. Conclusions: LAMS is an effective therapeutic option for benign GI strictures, offering high technical and early clinical success. However, the re-intervention rate after LAMS removal was high. In select cases, using LAMS placement as destination therapy with close surveillance is a reasonable option. [ABSTRACT FROM AUTHOR]

Background/objectives: Hepatic encephalopathy is the common manifestation of decompensated cirrhosis. The association between Helicobacter pylori (H. pylori) infection and hepatic encephalopathy has been shown in many epidemiologic studies. This meta-analysis was conducted to summarize all available studies to estimate the association between H. pylori infection and hepatic encephalopathy.Methods: A comprehensive literature review was conducted using MEDLINE and EMBASE database through March 2017 to identify studies that reported the association between H. pylori infection and hepatic encephalopathy. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird.Results: Of 15,233 studies, eleven studies (four cross-sectional, four case-control, and three cohort studies) met the eligibility criteria and were included in the meta-analysis. The pooled OR of hepatic encephalopathy in patients with H. pylori infection was 1.73 (95% CI 1.09-2.73) when compared with the patients without H. pylori infection. The association between H. pylori and hepatic encephalopathy was not statistically significant after the sensitivity analysis, excluding those using ELISA alone, with a pooled OR of 1.92 (95% CI 0.91-4.05, I 2 = 62%). There was no publication bias of overall included studies assessed by the funnel plots and Egger's regression asymmetry test.Conclusions: This study demonstrated a potential association between H. pylori infection and risk of hepatic encephalopathy. Future studies are required to assess the effect of chronicity of infection on the development of hepatic encephalopathy. [ABSTRACT FROM AUTHOR]

Background/aims: Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs., Methods: A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs)., Results: Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480)., Conclusions: Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.

Previous studies found seasonal variations in the incidence of retinal vascular occlusion (RVO), with more occurrence in winter. There is increasing evidence linking vitamin D deficiency and RVO. Therefore, we conducted a meta-analysis to evaluate the association between vitamin D levels and RVO. From inception to February 2024, MEDLINE and EMBASE databases were comprehensively searched. Observational studies comparing 25-hydroxyvitamin D (25(OH)D) levels between adult patients with RVO and non-RVO controls were included. We calculated pooled mean difference (MD) and pooled odds ratio (OR) with 95% confidence intervals (CI) of our data using a random-effects model and generic inverse variance method. Five studies involving 528 patients (228 patients with RVO and 300 controls were included in the meta-analysis. 25(OH)D was significantly lower in patients with RVO (pooled MD of -9.65 (95%CI -13.72 to -5.59, I2 = 92.2%). Vitamin D deficiency (serum 25(OH)D < 20) was significantly associated with RVO with the pooled OR of 14.52 (95%CI 1.72 to 122.59, I2 = 90.5). There was no difference in 25(OH)D levels between patients with central RVO and branched RVO (pooled MD of -0.94 (95%CI -3.91 to 2.03, I2 = 59.1%). In conclusion, our meta-analysis demonstrates that serum vitamin D levels were lower in patients with RVO than non-RVO controls. Clinicians could consider screening for vitamin D deficiency in patients with RVO. Further studies are warranted to determine the correlation between vitamin D levels and disease severity and the role of vitamin D supplements in these populations., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Apivatthakakul et al.)

Introduction: Obesity degrades fluoroscopic image quality and could impact on the endoscopic retrograde cholangiopancreatography (ERCP) outcomes. Our study aimed to compare the clinical outcomes and adverse events (AEs) between obese and non-obese patients undergoing ERCP for biliary stone-related conditions., Methods: Patients who underwent ERCP for biliary-stone related conditions were included. The analyzed outcomes included the rates of successful bile duct cannulation, incomplete bile duct stone clearance, recurrent bile duct stones, and AEs., Results: A total of 229 patients (116 obese patients and 113 non-obese patients) were included. All patients had successful bile duct cannulation. The rates of incomplete bile duct stone clearance (11.3% vs. 9.0%, P = 0.51), recurrent bile duct stones (1.9% vs. 4.2%, P = 0.24), and AEs (1.8% vs. 0.7%, P = 0.43) were not significantly different between the two groups, respectively., Conclusion: Our study demonstrates no associations between obesity and the rates of incomplete stone clearance, recurrent stones, successful cannulation, or AEs in patients undergoing ERCP for biliary stone-related disease., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aims: Coaxial double-pigtail plastic stent (DPPS) placement is often performed within lumen-apposing metal stents (LAMSs) for drainage of pancreatic fluid collections (PFCs) to prevent adverse events (AEs) such as stent occlusion and bleeding. This study compares the safety and outcomes of LAMSs alone versus LAMSs with coaxial DPPSs for PFC management., Methods: Patients undergoing drainage of a PFC with LAMSs were retrospectively identified and categorized as LAMS or LAMS/DPPS based on initial drainage strategy. The AE rate, AE type, and clinical success were extracted by chart review., Results: One hundred eighty-five individuals (83 LAMS, 102 LAMS/DPPS) were identified. No significant differences were found in rates of clinical success (75.9% LAMS vs 69.6% LAMS/DDPS, P = .34) or overall AEs (15.7% LAMS vs 15.7% LAMS/DPPS, P = .825)., Conclusions: In this comparative single-center study, placement of a coaxial DPPS for drainage of PFCs with LAMSs did not affect rates of AEs or clinical success., Competing Interests: Disclosure The following authors disclosed financial relationships: R. Law: Consultant for ConMed and Medtronic; royalties from UpToDate. A. C. Storm: Consultant for Apollo Endosurgery; research support from Apollo Endosurgery and Boston Scientific. B. T. Petersen: Consultant for Olympus America; investigator for Boston Scientific and Ambu. B. K. Abu Dayyeh: Consultant for Endogenex, Endo-TAGSS, Metamodix, BFKW, USGI, Apollo Endosurgery, Medtronic, Spatz Medical, EndoGastric Solutions, Aspire Bariatrics, and Boston Scientific; research support from Cairn Diagnostics, USGI, Apollo Endosurgery, Medtronic, Spatz Medical, EndoGastric Solutions, Aspire Bariatrics, and Boston Scientific; speaker for Olympus and Johnson & Johnson. V. Chandrasekhara: Consultant for Covidien LP and Boston Scientific; shareholder in Nevakar Corporation. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest.

Objective: Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG., Design: A priori - designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T 1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss., Results: 36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T 1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T 1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG., Conclusion: ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity., Trial Registration Number: NCT03406975., Competing Interests: Competing interests: ACS: research grant support from Apollo Endosurgery, Boston Scientific, Endogenex, Endo-TAGSS and Enterasense. Consultant for Apollo Endosurgery, ERBE, GI Dynamics, Intuitive and Olympus; AA: stockholder in Gila Therapeutics, Phenomix Sciences; consultant fees from Rhythm Pharmaceuticals, General Mills; BKAD: consulting fee from Endogenex, Endo-TAGSS, Metamodix and BFKW; consulting fee and grant/research support from USGI, Cairn Diagnostics, Aspire Bariatrics and Boston Scientific; speaker honorarium from Olympus and Johnson and Johnson; speaker honorarium and grant/research support from Medtronic and EndoGastric Solutions; and research support/grant from Apollo Endosurgery and Spatz Medical; MC: advisor to Phenomics Sciences, holder of stock options., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and study aims  Gastric outlet obstruction (GOO) is traditionally managed with surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is now a third option. Large studies assessing their relative risks and benefits with adequate follow-up are lacking. We conducted a comparative analysis of patients who underwent EUS-GE, ES, or surgical-GE for GOO. Patients and methods  In this retrospective comparative cohort study, consecutive patients presenting with GOO who underwent EUS-GE, ES, or surgical-GE at two academic institutions were reviewed and independently cross-edited to ensure accurate reporting. The primary outcome was need for reintervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AEs). Results  A total of 436 patients (232 EUS-GE, 131 ES, 73 surgical-GE) were included. The median duration of follow-up of the entire cohort was 185.5 days (interquartile range 55.25-454.25 days). The rate of reintervention in the EUS-GE group was lower than in the ES and surgical-GE groups (0.9 %, 12.2 %, and 13.7 %, P  < 0.0001). Technical success was achieved in 98.3 %, 99.2 %, and 100 % ( P  = 0.58), and clinical success was achieved in 98.3 %, 91.6 %, and 90.4 % ( P  < 0.0001) in the EUS-GE, ES, and surgical-GE groups, respectively. The EUS-GE group had a shorter LOS (2 days vs. 3 days vs. 5 days, P  < 0.0001) and a lower AE rate than the ES and surgical-GE groups (8.6 % vs. 38.9 % vs. 27.4 %, P  < 0.0001). Conclusion  This large cohort study demonstrates the safety and palliation durability of EUS-GE as an alternative strategy for GOO palliation in select patients., Competing Interests: Competing interests Dr. Abu Dayyeh is a consultant for Endogenex, Endo-TAGSS, Metamodix, and BFKW; is a consultant for and receives grant/research support from USGI, Boston Scientific; receives grant/research support from Cairn Diagnostics, Aspire Bariatrics; has speaker roles with Olympus, Johnson and Johnson; has speaker and grant/research support from Medtronic, Endogastric solutions; and has research support from Apollo Endosurgery, and Spatz Medical. Dr. Law is a consultant for ConMed and Medtronic. Dr. Chandrasekhara is a consultant for Boston Scientific, Covidien, and LP; a shareholder at Nevakar Corporation; and on the medical advisory board for Interpace Diagnostics. Dr. Storm is a consultant for Apollo Endosurgery, ERBE, GI Dynamics, and Olympus and received research grant support from Apollo Endosurgery, Boston Scientific, Endo-TAGSS, Endogenex, and Enterasense. Dr. Marya is a consultant for AnX Robotica. Dr. Kunda is a consultant of Boston Scientific, Omega Medical Imaging, Apollo Endosurgery, and Olympus, Ambu, M.I.Tech, Medconsgroup, EndiaTx, Q3 Medical – AMG International and Tigen Pharma., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and study aims  Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods  This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results  A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P  > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P  < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P  = 0.009). Conclusions  Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted., Competing Interests: Competing interests Dr. Abu Dayyeh is a consultant for Metamodix, BFKW, DyaMx, Boston Scientific, USGI medical, Hemostasis, and Endo-TAGSS. He has received research support from Apollo Endosurgery, USGI, Spatz Medical, Boston Scientific, GI Dynamics, Cairn Diagnostics, Aspire Bariatrics, and Medtronic. He has served as a speaker for Johnson & Johnson, EndoGastric Solutions, and Olympus. Dr. Janu is a consultant for EndoGastric Solutions, Ethicon/J&J, and Olympus. Dr. Murray is a consultant for Boston Scientific Corp, Pentax America. He has received research support from Pentax America. He has served as a speaker for AbbVie. He is an advisory board member for Colubris Rx. He has received royalties from UpToDate. Dr. Chang is a consultant for and has received educational research grants from EndoGastric Solutions, is a consultant for and has received educational grants from Cook and Olympus. Dr. Canto has received research support from EndoGastric Solutions and Pentax Medical Corporation and has received royalties from UpToDate., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic bariatric therapy that complements current medical and surgical therapeutic offerings for weight management and fills an unmet need. Few meta-analyses compared ESG to laparoscopic sleeve gastrectomy (LSG). However, these studies relied on indirect evidence derived from non-comparative studies. Comparative effectiveness data derived from direct comparative studies is needed. We performed a meta-analysis of studies that directly compared ESG with LSG., Methods: A comprehensive search of PubMed, Embase, and Cochrane databases was conducted. Single-arm studies were excluded. Pooled mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CIs) were obtained within a random-effect model., Results: Seven studies with 6,775 patients (3,413 with ESG vs. 3,362 with LSG) were included. There were significant differences in 6-month (MD - 7.48; 95% CI - 10.44, - 4.52; P < 0.00001), 12-month (MD - 9.90; 95% CI - 10.59, - 9.22; P < 0.00001), and 24-month (MD - 7.63; 95% CI - 11.31, - 3.94; P < 0.0001) TBWL% favoring LSG over ESG. There was a trend toward lower incidence of adverse events with ESG compared to LSG but did not reach statistical significance (RR 0.51, 95% CI 0.23-1.11, P = 0.09). The incidence of new-onset gastroesophageal reflux disease (GERD) was significantly lower after ESG compared to LSG, 1.3% vs. 17.9%, respectively (RR 0.10, 95% CI 0.02-0.53, P = 0.006)., Conclusions: ESG achieved clinically adequate but lower short- and mid-term weight loss when compared to LSG, with fewer adverse events, including GERD. Given the stomach-sparing nature of ESG and acceptable safety profile, it provides an acceptable alternative to LSG for patients with mild-to-moderate obesity., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Given the low survival rate in pancreatic cancer, new therapeutic techniques have been explored, especially for unresectable or borderline resectable disease. Endoscopic ultrasound (EUS) provides real-time imaging and minimally invasive access for local and targeted injection of anti-tumor agents directly into the pancreatic tumor. Limited studies have been reported using this technique for the treatment of pancreatic ductal adenocarcinoma (PDAC)., Aim: To evaluate the progress made with EUS-guided injectable therapies in the treatment of PDAC., Methods: All original articles published in English until July 15, 2021, were retrieved via a library-assisted literature search from Ovid Evidence-Based Medicine Reviews and Scopus databases. Reference lists were reviewed to identify additional relevant articles. Prospective clinical studies evaluating the use of EUS-guided injectable therapies in PDAC were included. Studies primarily directed at non-EUS injectable therapies and other malignancies were excluded. Retrieved manuscripts were reviewed descriptively with on critical appraisal of published studies based on their methods and outcome measures such as safety, feasibility, and effectiveness in terms of tumor response and survival. Heterogeneity in data outcomes and therapeutic techniques limited the ability to perform comparative statistical analysis., Results: A total of thirteen articles (503 patients) were found eligible for inclusion. The EUS-injectable therapies used were heterogeneous among the studies consisting of immunotherapy ( n = 5) in 59 patients, chemotherapy ( n = 1) in 36 patients, and viral and other biological therapies ( n = 7) in 408 patients. Eleven of the studies reviewed were single armed while two were double armed with one randomized trial and one non-randomized comparative study. Overall, the included studies demonstrated EUS-guided injectable therapies to be safe and feasible with different agents as monotherapy or in conjunction with other modalities. Promising results were also observed regarding their efficacy and survival parameters in patients with PDAC., Conclusion: EUS-guided injectable therapies, including immunotherapy, chemotherapy, and viral or other biological therapies have shown minimal adverse events and potential efficacy in the treatment of PDAC. Comparative studies, including controlled trials, are required to confirm these results in order to offer novel EUS-based treatment options for patients with PDAC., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Endoscopic bariatric therapies can help address widening management gaps in obesity. Their ability to facilitate weight loss is largely tied to influences on appetite through perturbations of gastric emptying and accommodation. As these tools gain traction in obesity therapy, their physiologic underpinnings require exploration, which may enhance efficacy, tolerance, and patient-tailored care., Methods: We prospectively assessed consecutive subjects with fluid-filled intragastric balloons (IGBs) ( n  = 18) placed between October 2016 and June 2017 or underwent endoscopic sleeve gastroplasty (ESG) ( n  = 23) from March 2018 to June 2018. Patients underwent physiologic appraisal at 3 months with 13 C-spirulina-based gastric emptying breath test to determine time to half emptying (T50), as well as maximum tolerated volume (MTV) of a standard nutrient drink test. Changes in T50 and MTV at 3 months were compared with percent total body weight loss (%TBWL) at 3 and 6 months using best-fit linear regression., Results: The change in T50 at 3 months correlated with %TBWL at 3 months for IGB ( P  = 0.01) and ESG ( P  = 0.01) but with greater impact on %TBWL in IGB compared to ESG ( R2  = 0.42 vs . 0.26). Change in T50 at 3 months was predictive of weight loss at 6 months for IGB ( P  = 0.01) but not ESG ( P  = 0.11). ESG was associated with greater decrease in MTV compared to IGB (340.25 ± 297.97 mL vs. 183.00 ± 217.13 mL, P  = 0.08), indicting an enhanced effect on satiation through decreased gastric accommodation. Changes in MTV at 3 months did not correlate with %TBWL for either IGB ( P  = 0.26) or ESG ( P  = 0.49) but trended toward significance for predicting %TBWL at 6 months for ESG ( P  = 0.06) but not IGB ( P  = 0.19)., Conclusion: IGB and ESG both induce weight loss but likely through distinct gastric motor function phenotypes, and gastric emptying may predict future weight loss in patients with IGB., (Copyright © 2022 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

Background and study aims  Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an endoscopic procedure for treating gastric outlet obstruction (GOO). Limited data exist regarding the safety and efficacy of EUS-GJ in patients with malignant GOO with ascites. Thus, we aimed to study the outcomes and safety of EUS-GJ in GOO patients with vs. without ascites. Patients and methods  This is a retrospective cohort study of patients with malignant GOO who underwent successful EUS-GJ at a tertiary care academic center. Primary outcomes included the efficacy and safety of EUS-GJ. Secondary outcomes included 30-day readmission, reintervention, and survival utilizing Kaplan-Meier analysis. Results  A total of 55 patients (mean age of 67.0 ± 11.3 years, 40.0 % female) who underwent EUS-GJ, of whom 24 had ascites (small in 22, large in 2) were included. Clinical success was achieved in 91.7 % and 93.5 % ( P =  1.00) of patients with and without ascites, respectively. A higher rate of adverse events (AEs) was noted in patients with ascites but this was not statistically significant (37.5 % vs. 19.4 %, P =  0.13). Four patients in the ascites group (16.6 %) developed clinical evidence of peritonitis or sepsis post-EUS-GJ. Eight patients with ascites developed worsening ascites within a month of EUS-GJ. In contrast, only one patient without ascites developed evidence of new ascites. The median survival of patients was not significantly different between the two groups (patients with ascites: 129 days vs. patients without ascites: 180 days, ( P =  0.12). Conclusions  The efficacy EUS-GJ in the presence of ascites is promising; however, the safety profile remains concerning given the high rate of AEs, specifically peritonitis and sepsis., Competing Interests: Competing interests Dr. Abu Dayyeh is a consultant for USGI, Medtronic, Boston Scientific, Hemostasis, Endogenex, and the recipient of research support from Apollo Endosurgery, USGI, Boston Scientific, Endogastric Solutions and Medtronic and a speaker for Olympus, Medtronic and Johnson and Johnson. Dr. Storm is a consultant for Apollo Endosurgery, GI Dynamics, Olympus, ERBE, and Enterasense, and the recipient of research support from Apollo Endosurgery, Endo-TAGSS, and Boston Scientific. Dr. Law is a consultant for ConMed and Medtronic. Dr. Chandrasekhara is a consultant for Interpace Diagnostics and Covidien LP, and a shareholder at Nevakar Corporation., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

The prevalence of obesity has been increasing on a global scale. However, less than 1% of patients eligible for bariatric surgery actually undergo weight loss surgery. Endobariatric therapies (EBTs) have emerged to bridge the obesity treatment gap, as they are less invasive, highly effective, and more broadly applicable to patients with mild to moderate obesity. Endoscopic sleeve gastroplasty and primary obesity surgery endoluminal are the two most promising EBTs, altering stomach physiologies mimicking bariatric surgery. This review focuses on these two EBT approaches.

Video 1Technique for complete endoscopic removal of the eroded and migrated LINX device using the Ovesco DC current retrieval system., (© 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Purpose: Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB., Methods: A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model., Results: Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I 2 = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I 2 = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m 2 (95% CI 36.49, 40.6 kg/m 2 ; I 2 = 92.1%) and after 1 year was 32.1 kg/m 2 (95% CI 25.50, 38.7 kg/m 2 ; I 2 = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I 2 = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I 2 = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I 2 = 0%)., Conclusion: This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce., Objectives: To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity., Setting: Academic referral centers, a retrospective cohort study., Methods: Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m 2 ) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared., Results: A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44)., Conclusion: RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In selected cases of post-bariatric leaks and fistulas, endoscopy is an initial treatment modality. Management can be complex and require multiple endoscopic sessions with varying degrees of success. Our aim was to describe our tertiary care experience on endoscopy management of refractory post-bariatric leaks and fistulas., Methods: Patients with post-bariatric leaks and/or fistulas who failed an initial endoscopic intervention were included. Endoscopic treatments were classified into four strategies: (1) closure management, (2) active drainage, (3) passive drainage, and (4) plugging. Clinical success and adverse events were assessed., Results: A total of 25 patients (mean age = 45.3 ± 11.8 years and 56% female) were included. Clinical success was achieved in 20 patients (80%) with a mean of 3.0 ± 1.5 procedures and a median time to healing of 114.5 (53-210.3) days. Closure and plugging were the main successful strategies used for early and acute leaks/fistulas, while drainage was for late and chronic leaks/fistulas. Adverse events were observed in 13 patients (52%) with one serious adverse event. Patients with fistulas had a lower success rate (72.2% vs. 100%, P = 0.052). Of those with clinical failure (n = 5), four underwent reconstructive surgery, eventually led to success in 3 patients. The other one died of septic shock related to a complicated fistula., Conclusions: Complex multi-modality endoscopic management ultimately achieved clinical success in most cases of refractory leaks/fistulas post-bariatric with an acceptable safety profile. However, a close follow-up to detect the development of long-term failure is warranted. These patients should be referred to a specialized bariatric center with expertise in bariatric endoscopy and surgery.

Background: Roux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes., Objective: To evaluate long-term outcomes of RNYG for failed fundoplication and its impact on esophageal function., Setting: A retrospective cohort study and a systematic review., Methods: Patients who underwent RNYG after failed fundoplication between 1995 and 2019 were identified. Surgical-related complications, GERD, dysphagia, and endoscopic and esophageal manometric findings were reviewed. A literature search for relevant studies was performed from several databases from database inception to September 2019., Results: A total of 101 patients (mean age, 52.1 yr; 86.1% female; mean body mass index, 35.8 kg/m 2 ) were included. Overall complication rates within and more than 30 days after surgery were 36.3% and 53.5%. GERD symptoms were resolved in 70.1% after RNYG. However, 39.7% had a recurrence during a median follow-up of 56.2 months. In patients with no baseline dysphagia (n = 36), 16 (44%) developed new-onset dysphagia after surgery. In patients with severe baseline dysphagia (n = 9), 5 patients (56%) had persistent dysphagia after surgery. Seven studies involving 381 patients were included in our systematic review. High rates of GERD improvement have been reported across studies; however, long-term GERD, dysphagia, and objective outcomes were infrequently reported., Conclusion: RNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort., Methods: Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months., Results: Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation., Conclusions: R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and study aims  Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods  Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results  Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P  < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting ( P  < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions  Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results., Competing Interests: Competing interests Dr. Buttar is a consultant of Medrobotics and Ovesco. Dr. Law is a consultant of Olympus, America, (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Gastric sleeve stenosis (GSS) is reported in .7% to 4% of cases after sleeve gastrectomy. Two endoscopic balloon dilation techniques are available with no clear consensus on the therapeutic approach., Objectives: To compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilations for GSS., Setting: Academic referral centers, United States and a meta-analysis., Methods: Consecutive patients who presented with GSS and underwent endoscopic hydrostatic and/or pneumatic balloon dilations at 3 tertiary care hospitals were included. Clinical success was defined as an improvement of symptoms that allowed the patient to avoid further interventions. A systematic literature search was performed to identify relevant studies for meta-analysis., Results: Of 46 patients, 13 had pneumatic dilation only, 26 had hydrostatic dilation only, and 7 had pneumatic dilation after failed hydrostatic dilation. Clinical success was not significantly different among the 3 groups with the success rates of 30.8%, 57.6%, and 57.1% (P = .25) after single dilation and 61.5%, 63.6%, and 71.4% (P = .90) after serial dilations in the pneumatic group, hydrostatic group, and pneumatic after failed hydrostatic group, respectively. Patients who failed hydrostatic balloon dilation (n = 7) had a success rate of 71.4% with subsequent pneumatic dilation. Two serious adverse events were observed in the pneumatic group, whereas none were observed in the hydrostatic group. A meta-analysis of 16 studies involving 360 patients demonstrated higher clinical success with single pneumatic balloon dilation compared with hydrostatic balloon dilation (62.2% versus 36.4%; P = .007) with higher adverse events (3 versus 0 events)., Conclusions: Hydrostatic balloon dilation should be considered as an initial modality for GSS given its acceptable success rate and high safety profile. In those who fail hydrostatic balloon dilation, a subsequent step-up approach to pneumatic balloon dilation or revisional surgery should be attempted., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Endoscopic bariatric and metabolic therapies can potentially reproduce similar gastric and small intestinal anatomic and physiologic manipulations as Roux-en-Y gastric bypass. This proof of concept animal study was aimed to assess the feasibility, safety, efficacy, and impact on gastrointestinal physiology of combined intragastric balloons (IGB) and duodenal-jejunal bypass liner (DJBL) for the treatment of obesity., Methods: Five Ossabaw pigs were fed a high-calorie diet to develop obesity and were randomly assigned to receive IGB or DJBL in sequence. The weight gain rate was calculated. Fasting and postprandial blood samples were drawn before any intervention (serving as the baseline group) and 1 month after second device insertion (serving as the combination group) to measure gut neurohormonal changes and metabolic parameters., Results: Four pigs successfully received a sequential device insertion. One pig developed duodenal sleeve prolapse that was spontaneously resolved. One pig was early terminated because of developing a central line infection. The rate of weight gain in the combination group (0.63 ± 1.3 kg/wk) was significantly lower than the baseline group (1.96 ± 2.17 kg/wk) and numerically lower than after insertion of the IGB (1.00 ± 1.40 kg/wk) or the DJBL (0.75 ± 2.27 kg/wk) alone. A trend of higher postprandial glucagon-like peptide-1 was observed in the combination group compared with the baseline group., Discussion: A combination of IGB and DJBL is feasible and well tolerated. A strategy of sequential use of these devices might offer a synergistic approach that can enhance weight loss and metabolic outcomes.

Introduction: To assess the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on acid reflux and esophageal motor function and to evaluate the observation of esophageal adenocarcinoma (EAC) after bariatric surgery., Methods: We searched 5 databases for adults who underwent SG or RYGB and had esophageal pH test and/or esophageal manometry before and after surgery. A separate systemic search of observational studies and a retrospective review at 3 institutions of adults who developed EAC after these surgeries were conducted. Outcomes were changes in manometric and pH parameters and EAC cases after SG and RYGB., Results: A total of 27 nonrandomized studies (SG: 612 patients; RYGB: 470 patients) were included. After SG, lower esophageal sphincter pressure and esophageal body amplitude were decreased and the risk of ineffective esophageal motility was increased. Total and recumbent acid exposure times were increased. After RYGB, an increased risk of ineffective esophageal motility was observed. Total, upright, and recumbent acid exposure times were decreased. The total reflux episodes remained unchanged but with increased nonacid reflux and decreased acid reflux events. Including our largest series, 31 EAC cases have been reported to date after SG and RYGB., Discussion: This systematic review demonstrates increased acid reflux after SG and decreased acid reflux after RYGB. An observed increased nonacid reflux after RYGB might contribute to failure of gastroesophageal reflux disease improvement. This refluxate might be noxious to the esophagus, warranting further studies. RYGB might not entirely preserve esophageal function as previously believed.

Background: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Studies have suggested that LSG can provide effective and sustainable weight loss although most of them were conducted in Western populations. Our aim was to characterize the midterm outcome of LSG in Asians with obesity., Methods: MEDLINE and EMBASE were searched through August 2019 for studies that reported % total body weight loss (TBWL) and/or % excess weight loss (EWL) at 3 and/or 5 years among adult Asians with obesity who underwent LSG. Data on complications and surgical revision rate were also extracted. The pooled effect size and 95% confidence interval (CI) were calculated using a random effects model., Results: A total of 19 studies involving 6235 patients were included. The pooled mean %EWLs were 72.6% (95% CI 67.2-78.0, I 2  = 97%); 67.1% (95% CI 61.7-72.6, I 2  = 95%); and 59.1% (95% CI 48.8-69.4, I 2  = 94%) at 1, 3, and 5 years, respectively. The pooled mean %TBWLs were 32.1%, 29.0%, and 25.5% at 1, 3, and 5 years, respectively. The pooled rates of revision due to gastroesophageal reflux disease and weight regain were 1.9% and 2.5%, respectively., Conclusions: Our meta-analysis suggests that LSG is an effective procedure for weight reduction that offers durable response for up to 5 years among Asians with obesity. The longer-term data is needed.

Background: Roux-en-Y gastric bypass surgery adversely affects bone health. The evidence is less well-described for sleeve gastrectomy (SG)., Objectives: To better characterize bone metabolism changes after SG., Setting: Systematic review and meta-analysis., Methods: MEDLINE and EMBASE were searched through March 2019 for eligible studies assessing adults with obesity aged 18 years or older that underwent SG. Bone mineral density (BMD), serum calcium, serum phosphate, serum 25-hydroxyvitamin D, serum parathyroid hormone, or serum alkaline phosphatase were reported at baseline and after SG; and a follow-up duration was at least 6 months. Preoperative and postoperative mean of each outcome of interest and corresponding standard deviations were extracted from each study and the mean difference (MD) was calculated. Pooled MD was then calculated by combining MDs of each study using random-effects model., Results: A total of 22 studies with 1905 patients with obesity that underwent SG were included. There were significant decreases in total hip BMD (pooled MD of -.06 g/cm 2 ; 95% confidence interval -.09 to -.03; I 2 = 0%) and femoral neck BMD (pooled MD of -.05 g/cm 2 ; 95% confidence interval -.09 to -.02; I 2 = 0%) after SG. No significant change in lumbar spine BMD was observed. There were significant increases in serum calcium, serum 25-hydroxyvitamin D, and serum phosphate. Serum parathyroid hormone was significantly decreased. Serum alkaline phosphatase was not significantly altered after SG., Conclusions: The present study found a decreased BMD among patients with obesity after SG., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The association between smoking and inflammatory bowel disease has long been recognized, but its role in the development of microscopic colitis is less well defined. This systematic review and meta-analysis was conducted with the aims to identify all available studies on the association between smoking and risk of microscopic colitis and to synthesize their results., Methods: The MEDLINE and EMBASE databases were searched from inception to May 2018 for cohort studies and case-control studies that compared the risk of microscopic colitis among current/former smokers vs individuals who have never smoked. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were extracted from the included studies and pooled together using a random-effects model, generic inverse variance method of DerSimonian and Laird. Between-study heterogeneity was quantified using the Q statistic and I2. Publication bias was assessed using funnel plots., Results: Seven studies (2 cohort studies and 5 case-control studies) with 262,312 participants met the eligibility criteria and were included in the meta-analysis. Relative to never-smokers, current smokers had significantly increased odds of microscopic colitis, with a pooled OR of 2.99 (95% CI, 2.15-4.15; I2, 64%). Former smokers also had significantly higher odds of microscopic colitis compared with never-smokers, with a pooled OR of 1.63 (95% CI, 1.37-1.94; I2, 0%). Funnel plots were symmetric and did not provide suggestive evidence of publication bias for both analyses., Conclusions: The current systematic review and meta-analysis found a significantly higher risk of microscopic colitis among current smokers compared with never-smokers. The risk attenuated among former smokers but remained significantly higher among never-smokers., (© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Acid secretion inhibitors are usually prescribed to promote the healing of artificial ulcers caused by endoscopic submucosal dissection (ESD) to reduce the risk of gastric perforation and delayed bleeding. Vonoprazan is a newer agent that has been shown to be more potent than a proton-pump inhibitor (PPI). However, it remains unclear whether vonoprazan is more effective than PPI in promoting healing of ulcers caused by ESD. Medline and Embase databases were searched through January 2018 for studies that compared the rate of complete healing of ulcers caused by ESD and post-ESD delayed bleeding in patients who received vonoprazan versus those who received PPI after ESD. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity was quantified using the Q-statistic and I. A total of six studies consisting of 461 patients were identified. The likelihood that ulcers caused by ESD were completely healed at 4-8 weeks after the procedure was significantly higher among patients who received vonoprazan compared with those who received PPI, with a pooled OR of 2.27 (95% CI=1.38-3.73; I=0%). The risk of developing post-ESD delayed bleeding was also numerically lower among those who received vonoprazan, with a pooled OR of 0.79, although the result did not reach statistical significance (95% CI=0.18-3.49; I=29%). This study found that patients who received vonoprazan after ESD had a significantly higher rate of completely healed ulcers compared with those who received PPI.

Purpose: Cecal intubation time (CIT) is an indicator for difficult colonoscopy which is associated with patients' unpleasant experience as well as increased risk of complications. Several studies have attempted to identify predictors for prolonged CIT but those studies tended to be small which gave rise to inconsistent and underpowered results. This systematic review and meta-analysis was conducted to summarize all available data., Methods: MEDLINE and EMBASE databases were searched through November 2017 for studies that investigated the factors for prolonged CIT. Only factors that were reported by at least three studies were included in the meta-analyses. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated using random effects model. The between-study heterogeneity of effect size was quantified using the Q statistic and I 2 ., Results: A total of nine studies involving 7131 patients were included. A total of six factors were analyzed. Patients with older age (≥ 65 versus < 65), female sex (versus male), low body mass index (BMI) (< 25 versus ≥ 25 kg/m 2 ), and poor bowel preparation (versus fair to good) had significantly longer CIT. The presence of diverticulosis and prior abdominal surgery were not significantly associated with prolonged CIT., Conclusions: The current meta-analyses have demonstrated that old age, female sex, low BMI, and poor bowel preparation were the predictors for prolonged CIT.

Purpose: Peri-procedural heparin is recommended as bridging therapy for patients with high thromboembolic risk who need to withhold anticoagulant for endoscopic submucosal dissection (ESD) for gastric neoplasms. However, little is known about the bleeding risk from heparin-bridging therapy itself., Methods: MEDLINE and EMBASE databases were searched through August 2017 for studies that compared the risk of post-ESD bleeding in patients who received heparin-bridging therapy in lieu of anticoagulant for gastric neoplasms and those who discontinued anticoagulant without receiving heparin. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity was quantified using the Q statistic and I 2 ., Results: A total of four studies consisting of 350 patients were identified. A significantly increased risk of post-ESD bleeding among the bridged patients compared with the non-bridged patients was observed with the pooled RR of 2.99 (95% CI, 1.51 to 5.92). The statistical heterogeneity was insignificant with I 2 of 0%., Conclusions: A significantly increased risk of post-ESD bleeding among patients who received heparin-bridging therapy in lieu of anticoagulant compared to patients who did not receive it was demonstrated in this study.

Purpose: Recent studies suggest that atrial fibrillation (AF) is associated with increased cardiovascular risk and mortality including sudden cardiac death (SCD). According to the Cardiovascular Heath Study cohort, the incident rate of SCD was higher in the AF population (2.9 per 1000 per year) compared with non-AF controls (1.3 per 1000 per year). In this study, we performed a systematic review and meta-analysis to explore the association between AF and SCD., Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to January 2017. Included studies were published prospective or retrospective cohort studies that compared the risk of developing SCD, defined by World Health Organization's criteria, in AF patients versus non-AF patients. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals., Results: Twenty-seven studies from January 1991 to February 2017 involving 8401 AF patients and 67,608 non-AF controls were included in this meta-analysis. Compared with controls, AF patients had a significantly higher risk of SCD in overall analysis (pooled risk ratio = 2.04, 95% confidence interval: 1.77-2.35, p < 0.01, I 2  = 42.66) as well as subgroups of general population studies, previous myocardial infarction or coronary artery disease, heart failure, hypertrophic cardiomyopathy (HCM), Brugada syndrome, and patients with either a pacemaker or implantable cardioverter defibrillator (ICD). In subgroup analysis of multivariate-adjusted studies, AF also had a significantly higher risk of SCD (pooled risk ratio = 2.22, 95% confidence interval = 1.59-3.09, p < 0.01, I 2  = 73.95). Incident rate of SCD in AF was 2-fold higher than controls but not statistically significant (pooled rate ratio = 2.06, 95% confidence interval = 0.66-7.53, p = 0.292, I 2  = 88.58)., Conclusions: Our meta-analysis demonstrates a statistically significant increased risk of SCD with AF in the general population and in those with previous myocardial infarction, coronary artery disease, heart failure, HCM, Brugada syndrome, and an implanted rhythm device.

Background/objective: Hepatitis C virus (HCV) infection is one of the most common infections worldwide. Recent epidemiologic studies have suggested that patients with HCV infection might be at an increased risk of Parkinson's disease. However, the data on this relationship remain inconclusive. This meta-analysis was conducted with the aim to summarize all available evidence., Patients and Methods: A literature search was performed using MEDLINE and EMBASE database from inception to May 2017. Studies that reported relative risks, odd ratios (ORs), or hazard ratios comparing the risk of Parkinson's disease among HCV-infected patients versus participants without HCV infection were included. Pooled OR and 95% confidence interval were calculated using a random-effect, generic inverse variance method., Results: Of 468 studies, five studies with 323 974 participants met our eligibility criteria and were included in the analysis. We found a higher risk of Parkinson's disease among patients with chronic HCV infection compared with participants without HCV infection with the pooled OR of 1.35 (95% confidence interval: 1.19-1.52). The statistical heterogeneity of this study was insignificant (I=3%). The main limitation of this meta-analysis was the limited accuracy of diagnosis in the primary studies as they were coding-based studies., Conclusion: This study demonstrated a higher risk of Parkinson's disease among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in the clinical picture.

Aim: To investigate the prevalence and association of Helicobacter pylori ( H. pylori ) with end-stage renal disease (ESRD)., Methods: SA comprehensive literature search was completed from inception until October 2016. Studies that reported prevalence, relative risks, odd ratios, hazard ratios or standardized incidence ratio of H. pylori among ESRD patients were included. Participants without H. pylori were used as comparators to assess the association between H. pylori infection and ESRD. Pooled risk ratios and 95%CI was calculated using a random-effect model. Adjusted point estimates from each study were combined by the generic inverse variance method of DerSimonian and Laird., Results: Of 4546 relevant studies, thirty-seven observational studies met all inclusion criteria. Thirty-five cross-sectional studies were included in the analyses to assess the prevalence and association of H. pylori with ESRD. The estimated prevalence of H. pylori among ESRD patients was 44% (95%CI: 40%-49%). The pooled RR of H. pylori in patients with ESRD was 0.77 (95%CI: 0.59-1.00) when compared with the patients without ESRD. Subgroup analysis showed significantly reduced risk of H. pylori in adult ESRD patients with pooled RR of 0.71 (95%CI: 0.55-0.94). The data on the risk of ESRD in patients with H. pylori were limited. Two cohort studies were included to assess the risk of ESRD in patients with H. pylori . The pooled risk RR of ESRD in patients with H. pylori was 0.61 (95%CI: 0.03-12.20)., Conclusion: The estimated prevalence of H. pylori in ESRD patients is 44%. Our meta-analysis demonstrates a decreased risk of H. pylori in adult ESRD patients., Competing Interests: Conflict-of-interest statement: The authors deny any conflict of interest.

Background/aims: No medications have been approved for managing nonalcoholic fatty liver disease (NAFLD). Lifestyle intervention is the mainstay for its treatment. Hyperferritinemia, which appears to be associated with the severity of liver injury and insulin resistance, is frequently observed in patients with NAFLD., Patients and Methods: We conducted a systematic review and meta-analysis of the outcomes of four interventional trials regarding the effect of phlebotomy in patients with NAFLD versus the outcomes of NAFLD patients who did not undergo phlebotomy. Primary outcome was the pooled mean difference (MD) of the homeostasis model assessment of insulin resistance (HOMA-IR). The secondary outcomes were the changes in liver enzymes and the lipid profile., Results: Four interventional studies involving 438 participants were included in the meta-analysis. HOMA-IR was lower in patients who underwent phlebotomy, with an MD of 0.84 [95% confidence interval (CI) 0.01 to 1.67, I2 = 72%]. Phlebotomy also significantly reduced the alanine aminotransferase (MD = 10.05, 95% CI 7.19-12.92, I2 = 34%) and triglyceride (MD = 9.89, 95% CI 4.96-14.83, I2 = 22%) levels and increased the high-density cholesterol level (MD = 3.48, 95% CI 2.03-4.92, I2 = 18%)., Conclusion: Phlebotomy decreased insulin resistance and liver transaminase levels in patients with NAFLD. In addition, it improved their lipid profile., Competing Interests: There are no conflicts of interest.

Background: Coronary heart disease is now the leading cause of death. Diagnosing myocardial infraction (MI) needs cardiac marker in case of equivocal clinical presentations and EKG interpretations. Troponin yields high sensitivity and specificity and could be used as a single screening assay. However, in actual practice, clinicians send CK-MB activity (CKMBa) as a combined marker with an expectation of providing additional diagnostic value due to large historical data. Discordant results from both markers lead to unclear management. Our study was to determine whether CKMBa has potential benefit for initial screening of MI in addition to cardiac troponin T (cTpT) in the Emergency Department (ED), and can this marker be safely removed from the routine laboratory panel in the emergency setting in Thailand., Material and Method: We conducted a retrospective cohort single-center study to examine the usefulness of CKMBa in the ED from 907 patients who presented with clinically suspected acute M, and investigated with both biomarkers (CKMBa and cTpT). In these patients, 97 patients were included in the final analysis as they had negative cTpT associated with positive CKMBa or CKMBa turned to be positive within 24 hours after serial biomarkers measurements. The outcome was assessed by the final diagnosis, the cause of death if patients died during admission, and the 180-day mortality from medical chart review. In patients highly suspectedfor MI, further investigations were done including echocardiogram, exercise stress test, and coronay angiogram by experienced cardiologists., Results: During the studyperiod, cTpTwere sent 1,772 times and most (95.2%) ofthe samples were associated with CKMBa results. The outcome showed that no one with negative cTpT was diagnosed as MI on a discharge diagnosis. Fourteen patients died during admission. The definitive cause was not defined as MI. The 180-day mortality was zero. During the follow-up, there was no MI suspected issues that needed further cardiac evaluations. The positive predictive value of CKMBa with negative cTpT was 0% (95% CI, 0-0.047)., Conclusion: CKMBa added no benefit to cTpT in diagnosing acute MI in ED. Removing CKMBa from emergency panel could be considered.