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Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy.
Gkolfakis, P, Tziatzios, G, Dimitriadis, GD, Triantafyllou, K
Endoscopy. 2018;(7):671-683
Abstract
BACKGROUND The usefulness of purgative preparation before small-bowel video capsule endoscopy is controversial. We aimed to examine the effect of purgative preparation on small-bowel video capsule endoscopy outcomes. METHODS We performed literature searches in MEDLINE and the Cochrane library for randomized controlled trials evaluating the effect of purgative preparation (polyethylene glycol, sodium phosphate, others) vs. clear-liquid diet/fasting in patients undergoing small-bowel capsule endoscopy. Meta-analysis outcomes included the examination's diagnostic yield, small-bowel mucosal visualization quality, the examination's completion rate, and gastric and small-bowel transit times. The effect size on study outcomes was calculated using a fixed- or random-effect model, as appropriate, and is shown as the risk ratio (RR) with 95 % confidence interval (CI). RESULTS We identified 12 eligible trials with 17 sets of data including 1221 subjects. Significant heterogeneity was detected with no evidence of publication bias. As compared with clear-liquid diet, purgative bowel preparation did not increase capsule endoscopy diagnostic yield (RR 1.17 [95 %CI 0.97 to 1.40]; P = 0.11). Neither the small-bowel mucosal visualization quality (RR 1.14 [95 %CI 0.96 to 1.35]; P = 0.15) nor completion rate for the examination (RR 0.99 [95 %CI 0.95 to 1.04]; P = 0.76) significantly improved after purgative preparation. Purgatives also had no effect on video capsule endoscopy gastric and small-bowel transit times. CONCLUSIONS Our analysis challenges the usefulness of purgative preparation for improving the diagnostic yield of small-bowel video capsule endoscopy and the quality of small-bowel mucosal visualization.
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Single versus double balloon enteroscopy for small bowel diagnostics: a systematic review and meta-analysis.
Lipka, S, Rabbanifard, R, Kumar, A, Brady, P
Journal of clinical gastroenterology. 2015;(3):177-84
Abstract
INTRODUCTION Double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) are 2 types of commonly used balloon-assisted enteroscopic techniques for "deep enteroscopy." Although there are several randomized controlled trials assessing the superiority of DBE compared with SBE, the results from individual randomized controlled trials seem conflicting. We performed a systematic review and meta-analysis to assess the efficacy of DBE compared with SBE. METHODS Primary outcomes were diagnostic and therapeutic yield. Secondary outcomes were failure rates, adverse events, complete enteroscopy, anterograde/retrograde insertion depths, and procedure times. We searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until February 28, 2014, as well as other databases. For quality assurance purposes throughout the systematic review process, dual extraction was performed. The systematic review was performed as per the standards of Cochrane collaboration. RESULTS Four trials enrolling a total of 375 patients were included. DBE did not offer an advantage over SBE in therapeutic yield [risk ratio (RR), 1.11; 95% confidence interval (CI): 0.90, 1.37; P=0.33)] or diagnostic yield (RR=1.08; 95% CI: 0.89, 1.32; P=0.42), failure rates (RR=0.68; 95% CI: 0.23, 2.05; P=0.5), overall adverse events (RR=1.41; 95% CI: 0.32, 6.3; P=0.65), or complete enteroscopy rates (RR=1.73; 95% CI: 0.86, 3.48; P=0.12). No evidence existed for an advantage of anterograde or retrograde procedure time between these 2 modalities [mean difference (MD), 3.78; 95% CI, -30.76, 38.32; P=0.83; and MD, -0.53; 95% CI: -7.66, 6.59; P=0.88, respectively]. Neither anterograde nor retrograde insertion depths appeared to differ between the 2 studies analyzed (MD, -7.36; 95% CI: -40.36, 25.64; P=0.66 and MD, 7.86; 95% CI: -12.68, 28.40; P=0.45, respectively). CONCLUSIONS Performance of SBE and DBE appears to be similar in terms of diagnostic/therapeutic yield, insertion depths, procedure time, complete enteroscopy, failure rates, or adverse events.
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Diagnostic yield of small-bowel capsule endoscopy in patients with iron-deficiency anemia: a systematic review.
Koulaouzidis, A, Rondonotti, E, Giannakou, A, Plevris, JN
Gastrointestinal endoscopy. 2012;(5):983-92
Abstract
BACKGROUND Iron-deficiency anemia (IDA) is the most common cause of anemia worldwide. Current guidelines recommend the use of small-bowel capsule endoscopy (SBCE) in IDA. Evidence of the validity of SBCE in patients with IDA alone is still limited. OBJECTIVE To assess the diagnostic yield (DY) of SBCE in IDA by pooling data from relevant studies. DESIGN Systematic review and meta-analysis. Fixed-effects or random-effects models were used as appropriate. SETTING Studies that estimated the DY of SCBE in IDA were identified. Two investigators independently conducted the search and data extraction. PATIENTS A total of 24 studies enrolling 1960 patients with IDA who underwent SBCE were included. MAIN OUTCOME MEASUREMENTS Per-patient DY, with 95% confidence intervals. Subgroup analysis was also performed. RESULTS The pooled DY of SBCE in IDA, evaluated by a random-effects model, was 47% (95% CI, 42%-52%), but there was statistically significant heterogeneity among the included studies (inconsistency index [I(2)] = 78.8%, P < .0001). The pooled DY of SBCE in studies focused solely on patients with IDA (subset 1, 4 studies) was 66.6% (95% CI, 61.0%-72.3%; I(2) = 44.3%); conversely, that of studies not focusing only on IDA patients (subset 2, 20 studies) was 44% (95% CI, 39%-48%; I(2) = 64.9%). In particular, more vascular (31% vs 22.6%, P = .007), inflammatory (17.8% vs 11.3%, P = .009), and mass/tumor (7.95% vs 2.25%, P < .0001) lesions were detected with SBCE in patients participating in the studies in subset 1. LIMITATIONS Heterogeneity of studies, retrospective design, and selection bias. CONCLUSIONS This analysis demonstrates the validity of SBCE in the investigation of patients with IDA and negative findings on a previous diagnostic workup, although certain factors such as heterogeneity and quality of the included studies should be taken into account.
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Meta-analysis: efficacy of small bowel preparation for small bowel video capsule endoscopy.
Belsey, J, Crosta, C, Epstein, O, Fischbach, W, Layer, P, Parente, F, Halphen, M
Current medical research and opinion. 2012;(12):1883-90
Abstract
OBJECTIVE It is unclear whether small bowel visibility in video capsule endoscopy (VCE) is enhanced by the use of bowel preparation in addition to pre-procedural fasting. The objective of this study was to clarify this issue by means of a systematic review of the literature and meta-analysis. METHODS Randomised controlled trials comparing the use of laxative bowel preparation with fasting alone were identified using a literature search. Categorical measures of treatment efficacy were extracted from qualifying studies and pooled using random-effects meta-analyses. Primary analysis compared any bowel preparation with fasting alone; subsidiary analyses assessed diagnostic yield and results for each regimen. RESULTS Eight studies were identified, using either polyethylene glycol (PEG) or sodium phosphate (NaP) based regimens. No qualifying studies were identified using other laxatives. Study quality was sufficiently high to warrant meta-analysis. Use of any form of bowel preparation yielded significantly better visibility than fasting alone (OR = 2.31; 95% CI = 1.46-3.63; p < 0.0001). Similar results were seen for diagnostic yield (OR = 1.88; 95% CI = 1.24-2.84; p = 0.023). When sub-analysed according to the treatment used, PEG-based regimens showed benefit (OR = 3.11; 95% CI = 1.96-4.94; p < 0.0001), while NaP-based regimens yielded no significant difference from fasting alone (OR = 1.32; 95% CI = 0.59-2.96; p < 0.0001). LIMITATIONS The study did not consider results from retrospective studies, nor those which did not give a categorical measure of efficacy. The impact of prokinetic and other adjunctive treatments was not considered. The results are only relevant to the most commonly used video capsule, as data for newer alternative devices have not yet been published. CONCLUSION Based on the results of this analysis, the use of bowel preparation alongside fasting is recommended for VCE. PEG-based regimens offer a clear advantage in these patients, while the currently available evidence base does not support the use of NaP. For VCE, lower volume PEG appears to be as efficacious as higher volumes traditionally used for colonoscopy preparation.
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Laparoscopic versus Open surgery for small bowel Crohn's disease.
Dasari, BV, McKay, D, Gardiner, K
The Cochrane database of systematic reviews. 2011;(1):CD006956
Abstract
BACKGROUND Crohn's disease (CD) is a chronic inflammatory bowel disease that most commonly involves the terminal ileum and colon (55 percent). Surgical treatment is required in approximately 70 percent of patients. Multiple procedures and repeat operations are required in 30 - 70 percent of all patients (Duepree 2002) but the disease remains incurable.Laparoscopy has gained wide acceptance in gastrointestinal surgery with potential advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, better cosmesis (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), improved social and sexual interaction (Albaz 2000) and its use is accepted in benign and malignant colorectal diseases. Laparoscopic surgery offers additional advantage of smaller abdominal fascial wounds, low incidence of hernias, and decreased rate of adhesive small-bowel obstruction (Albaz 2000) compared with conventional surgery reducing the need for non-disease-related surgical procedures in CD population.There are concerns about missing occult segments of disease and critical proximal strictures due to limited tactile ability, earlier recurrence due to possible reduced immune response induced by laparoscopy, technical difficulty due to fragile inflamed bowel and mesentery and the existence of adhesions, fistulas, and abscesses (Uchikoshi 2004). It is therefore important to evaluate the potential benefits and risks of laparoscopic surgery versus open surgery in patients with small bowel CD (Lowney 2005). OBJECTIVES To determine if there is a difference in the perioperative outcomes and re-operation rates for disease recurrence following laparoscopic surgery compared to open surgery in small bowel CD. SEARCH STRATEGY Published and unpublished randomised controlled trials were searched for in the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) 2010 issue 2 The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects (DARE) 2010 issue 2 The Cochrane Colorectal Cancer Group Controlled Trials Register Ovid MEDLINE (1990 to 2010) EMBASE (1990 to 2010) Health Technology Assessment (HTA) Database (1990 to 2010) SELECTION CRITERIA Randomised controlled trials (RCT) comparing laparoscopic and open surgery for small bowel CD were included. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies and extracted data. RevMan 5.0 was used for statistical analysis. MAIN RESULTS Two RCTs comparing laparoscopic and open surgery for small bowel CD were identified. Long term outcomes of the patients in both the trials were published separately and these were included in the review.Laparoscopic surgery appeared to be associated with reduced number of wound infections (1/61 vs 9/59), reoperation rates for non disease related complications (3/57 vs 7/54 ) but the difference was not statistically significant [p values were 0.23 and 0.19 respectively]. There was no statistically significant difference between any of the compared outcomes between laparoscopic and open surgery in the management of small bowel CD. AUTHORS' CONCLUSIONS Laparoscopic surgery for small bowel CD may be as safe as the open operation. There was no significant difference in the perioperative outcomes and the long term reoperation rates for disease-related or non-disease related complications of CD.