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Background Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results. Methods We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence. Results 1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 – 85.5, I 2 = 29) and 88.1 % (95 %CI 83.6 – 91.4, I 2 = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 – 96.9, I 2 = 0) and 96.7 % (95 %CI 94.0 – 98.2, I 2 = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 – 99.1, I 2 = 0) and 89.3 % (95 %CI 86.6 – 91.5, I 2 = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 – 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 – 6.8) and 3.7 % (95 %CI 2.3 – 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 – 10.0). Conclusion EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.

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Incidence and Natural history (CRC-SPIN). However, there are significant limitations as to the reliability and validity of even very sophisticated models, and the cascading effects of small inaccuracies in the underlying assumptions and input data can magnify errors in the eventual model outcomes. Thus, modeling data should never be considered to be at the same quality level as direct prospective or even retrospective clinical data. Second, one must keep in mind that the ACS guidelines specifically do not "apply cost and resource use as a decision-making criterion for recommendations." 7 Thus, some of the ACS recommendations may be cost effective (with an attractive "efficiency ratio" in ACS parlance) but nevertheless be very costly from a societal perspective. Finally, access and endoscopic capacity must be taken into consideration. Although studies may suggest that current endoscopic capacity in the United States can accommodate the additional screening needs of younger patients, 8 clinicians on the front lines of patient care are well aware that even in large cities (such as Seattle), the focus of many practices on more financially remunerative screening and surveillance colonoscopies has resulted in long wait times for patients with actual GI symptoms. The ACS is to be commended for their extensive and thorough review of all available data, but the fact remains that their new recommendations are currently based on emerging epidemiologic trends and modeling data. Previous data on screening colonoscopy in patients younger than 50 did not demonstrate high yields back in 2002. 9 Although it is understood that epidemiologic changes have occurred since then, it may be prudent to take a step back and allow more direct data to accumulate before a policy change is made that may have momentous repercussions for the entire health care system in the United States.

Background Gastric variceal bleeding carries significant mortality in the setting of portal hypertension. Among the endoscopic treatment options, endoscopic ultrasound (EUS)-guided glue and/or coil injection is a novel approach, but its role in the treatment of gastric varices is not established due to a lack of robust data. Methods We conducted a comprehensive search of several databases (inception to June 2019) to identify studies evaluating EUS in the treatment of gastric varices. Our primary goals were to estimate the pooled rates of treatment efficacy, obliteration and recurrence of gastric varices, early and late rebleeding, and adverse events with EUS-guided therapy in gastric varices. We also searched for studies that evaluated direct endoscopic glue (END-glue) injection for treatment of gastric varices, and used the pooled rates as comparators. Results 23 studies (851 patients) evaluating EUS-guided therapy were included. The pooled treatment efficacy was 93.7 % (95 % confidence interval [CI] 89.5 – 96.3, I 2 = 53.7), gastric varices obliteration was 84.4 % (95 %CI 74.8 – 90.9, I 2 = 77), gastric varices recurrence was 9.1 % (95 %CI 5.2 – 15.7, I 2 = 32), early rebleeding was 7.0 % (95 %CI 4.6 – 10.7, I 2 = 0), and late rebleeding was 11.6 % (95 %CI 8.8 – 15.1, I 2 = 22). The rates were comparable to END-glue therapy (28 studies, 3467 patients) except for obliteration, which was significantly better with EUS-guided therapy. On subgroup analysis, EUS-coil/glue combination showed superior outcomes. Conclusions EUS-guided therapy demonstrated clinical efficacy for treatment of gastric varices in terms of obliteration, recurrence, and long-term rebleeding, and may be superior to END-glue.

Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a new endoscopic procedure to perform ERCP in Roux-en-y gastric bypass (RYGB) patients. The aim of this study was to conduct a systematic review and meta-analysis to evaluate technical success, clinical success and adverse effects of EDGE and compare it to laparoscopic ERCP (LA-ERCP) and balloon ERCP (BE-ERCP). Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, LILACS, SCOPUS, and Web of Science databases to identify studies reporting on EDGE, LA-ERCP, and BE-ERCP. The primary outcome was to evaluate technical and clinical success of all three procedures and the secondary analysis focused on calculating the pooled rate of all adverse events (AEs), along with the commonly reported AE subtypes. Results Twenty-four studies on 1268 patients were included in our analysis with the majority of the population being males with mean age 53.72 years. Pooled rates of technical and clinical success with EDGE wer 95.5 % and 95.9 %, with LA-ERCP were 95.3 % and 92.9 % and were BE-ERCP were 71.4 % and 58.7 %, respectively. Pooled rates of all AEs with EDGE were 21.9 %, with LA-ERCP 17.4 % and with BE-ERCP 8.4 %. Stent migration was the most common AE with EDGE with 13.3 % followed by bleeding with 6.6 %. Conclusion Our meta-analysis demonstrated that the technical and clinical success of EDGE procedure is better than BE-ERCP and comparable to that of LA-ERCP in RYGB patients. EDGE also has a similar safety profile as compared to LA-ERCP but has higher AE rate as compared to BE-ERCP.

Introduction: Endoscopic retrograde cholangiopancreatography is the preferred method in biliary drainage. Endoscopic ultrasound (EUS) guidance has shown tremendous success in situations where endoscopic retrograde cholangiopancreatography fails or is contraindicated. EUS-guided choledochoduodenostomy (CDD) in particular is gathering a lot of interest due to its ease, and high rates of success. The reported adverse events with this procedure have been inconsistent among studies. Methods: We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the risk of adverse events, and the commonly reported subtype of adverse events in EUS-CDD. The secondary outcome was to estimate the pooled technical and clinical success rates. Results: Thirteen studies including 572 patients underwent biliary drainage with EUS-CDD. The pooled rate of all adverse events was 0.136 (95% confidence interval, 0.097-0.188; P=0.01) with moderate heterogeneity (I 2=56.9), and pooled rate of cholangitis was 4.2%, bleeding was 4.1%, bile leak was 3.7%, and perforation was 2.9%. On subgroup analysis, the pooled rate of adverse events with the use of lumen-apposing metal stent was 9.3% (95% confidence interval, 4.8-17.3). Conclusions: On the basis of our analysis EUS-CDD has an adverse event risk of 13.4%, which is lowest reported in literature so far. Reported adverse rates appeared to be lower with the use of lumen-apposing metal stent, except for perforation.

Background Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy. Methods We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis. Results 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 – 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 – 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 – 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 – 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 – 75.7; I 2 90). Conclusion Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.