Neostigmine Versus Colonoscopic Decompression for Acute Colonic Pseudo-Obstruction Not Resolving With Conservative Measures: A Meta-Analysis.

Introduction: Acute colonic pseudo-obstruction is an uncommon but not infrequent encounter among hospitalized patients. The American Society for Gastrointestinal Endoscopy recommended neostigmine first before colonoscopy; however, the Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery acknowledge the lack of evidence in the superiority of one approach over the other. This is the first meta-analysis aimed to fill this gap of evidence by including studies comparing neostigmine and colonoscopy in resolving the pseudo-obstruction.

Materials And Methods: This study was registered with the International Prospective Register of Systematic Reviews (CRD42024497631) and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The electronic databases PubMed, EMBASE, and Cochrane were searched for studies in English language comparing the two interventions and reporting on resolution of pseudo-obstruction as the primary outcome. The statistical analysis was conducted using RevMan version 5:4. The results were expressed in odd ratio with their confidence intervals.

Results: Of the 10 initially identified papers, only three met the inclusion criteria, all retrospective cohort studies. Out of the 64 patients receiving neostigmine, 30 were successful (47%) compared to 64 successful colonoscopic decompressions out of the 77 (83%). On random-effect analysis, colonoscopy was five times more likely to be successful compared to neostigmine odds ratio 5.45, 95% confidence interval [2.47-12.04]; P < 0.0001.

Conclusions: Currently there is no randomized controlled trial to serve as a guidance, but this meta-analysis suggests that colonoscopy is likely superior to neostigmine in resolving acute colonic pseudo-obstruction following failure of conservative management.