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Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis.

ABSTRACT: A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle-Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81-0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45-4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24-2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17-5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12-4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23-7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.

SUBMITTER: Jung DH

PROVIDER: S-EPMC8197794 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Video 1Cost-effective modified endoscopic vacuum therapy for GI transmural defects. Step-by-step process of manufacturing and potential advantages.1.Cut half gauze to the ideal size to cover only the fenestrated portion of the nasogastric tube (NGT).2.Wrap the gauze around the fenestrated portion of the NGT. The assistance of another person is important in this process.3.Cut the antimicrobial incise drape to match the size of the fenestrated portion of the NGT. Note that the incise drape is a very strong adhesive; therefore, 3 people are usually required to assemble it properly.4.Next, the suture is used to fix the gauze and drape to the NGT. Perform fixation of the modified sponge in 3 places. The first knot is in the proximal portion, just below the last fenestra of the NGT, as a marker of where the vacuum system starts. The second knot is at the distal end, to avoid migration of the modified sponge. The third knot is in the middle of the modified sponge, which is essential to serve as a guide during endoscopic placement. For example, in cases of defects without collection in which the sponge will be placed in an intraluminal position, it is ideal to place the vacuum system in the middle of the defect; in cases of intracavitary placement, it will work as a guide to how much of the modified sponge will be inside the collection.5.Finally, use a needle to make innumerable punctures in the modified sponge system to obtain adequate aspiration. An 18G needle is recommended because, in addition to having an adequate diameter, it is very sharp, which facilitates perforation of the modified sponge system.6.After creation of the modified endoscopic vacuum therapy, the functionality test is performed. Turn on the wall suction system, connect the distal end of the NGT to the tube of the canister connected on the wall, and place the NGT inside a bowl with a liquid solution. The aspiration of a large amount of liquid indicates proper functioning of the modified endoscopic vacuum therapy system.7.The device is then ready to be positioned endoscopically in the patient. After proper positioning, connect the NGT to the suction tube to avoid migration of the device upon removal of the scope.8.In addition to the cost-effective device as described, in our practice we also use wall suction to reduce costs associated with the use of the vacuum machine.9.Use the antimicrobial incise drape to seal the connection between the NGT and the suction tube to avoid leakage within the connection.10.Last, owing to instability of the negative wall pressure, a 20F intravenous catheter is connected to the tube to maintain a negative pressure between -75 and -150 mmHg, as confirmed by laboratory studies performed by our group.

Project description:Background: Several risk scores have attempted to risk stratify patients with acute upper gastrointestinal bleeding (UGIB) who are at a lower risk of requiring hospital-based interventions or negative outcomes including death. This systematic review and meta-analysis aimed to compare predictive abilities of pre-endoscopic scores in prognosticating the absence of adverse events in patients with UGIB. Methods: We searched MEDLINE, EMBASE, Central, and ISI Web of knowledge from inception to February 2023. All fully published studies assessing a pre-endoscopic score in patients with UGIB were included. The primary outcome was a composite score for the need of a hospital-based intervention (endoscopic therapy, surgery, angiography, or blood transfusion). Secondary outcomes included: mortality, rebleeding, or the individual endpoints of the composite outcome. Both proportional and comparative analyses were performed. Results: Thirty-eight studies were included from 2153 citations, (n = 36,215 patients). Few patients with a low Glasgow-Blatchford score (GBS) cutoff (0, ≤1 and ≤2) required hospital-based interventions (0.02 (0.01, 0.05), 0.04 (0.02, 0.09) and 0.03 (0.02, 0.07), respectively). The proportions of patients with clinical Rockall (CRS = 0) and ABC (≤3) scores requiring hospital-based intervention were 0.19 (0.15, 0.24) and 0.69 (0.62, 0.75), respectively. GBS (cutoffs 0, ≤1 and ≤2), CRS (cutoffs 0, ≤1 and ≤2), AIMS65 (cutoffs 0 and ≤1) and ABC (cutoffs ≤1 and ≤3) scores all were associated with few patients (0.01–0.04) dying. The proportion of patients suffering other secondary outcomes varied between scoring systems but, in general, was lowest for the GBS. GBS (using cutoffs 0, ≤1 and ≤2) showed excellent discriminative ability in predicting the need for hospital-based interventions (OR 0.02, (0.00, 0.16), 0.00 (0.00, 0.02) and 0.01 (0.00, 0.01), respectively). A CRS cutoff of 0 was less discriminative. For the other secondary outcomes, discriminative abilities varied between scores but, in general, the GBS (using cutoffs up to 2) was clinically useful for most outcomes. Conclusions: A GBS cut-off of one or less prognosticated low-risk patients the best. Expanding the GBS cut-off to 2 maintains prognostic accuracy while allowing more patients to be managed safely as outpatients. The evidence is limited by the number, homogeneity, quality, and generalizability of available data and subjectivity of deciding on clinical impact. Additional, comparative and, ideally, interventional studies are needed.

Project description:IntroductionWith increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient's quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis.MethodsData was prospectively collected on the use of Hemospray from 16 centres (January 2016-November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy.ResultsA total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0-9). The median Rockall score was six (interquartile range 5-7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray.ConclusionHemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

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Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis.

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