Gastrointestinal endoscopy in the elderly: current issues

An interpretable artificial neural network model for predicting hypoxemia via an online tool in adult (18-64) patients during esophagogastroduodenoscopy

Background

The hypoxemia risk in adult (18-64) patients treated with esophagogastroduodenoscopy (EGD) under sedation often poses a dilemma for anesthesiologists. We aimed to establish an artificial neural network (ANN) model to solve this problem, and introduce the Shapley additive explanations (SHAP) algorithm to further improve the interpretability.

Methods

The relevant data of patients underwent routine anesthesia-assisted EGD were collected. Elastic network was used to filter the optimal features. Airway-ANN and Basic-ANN models were established based on all collected indicators and remaining variables excluding airway assessment indicators, respectively. The performance of Basic-ANN, Airway-ANN and STOP-BANG was evaluated by the area under the precision-recall curve (AUPRC) on temporal validation set. The SHAP was used for revealing the predictive behavior of our best model.

Results

999 patients were eventually included. The AUPRC value of Airway-ANN model was significantly higher than Basic-ANN model in the temporal validation set (0.532 vs 0.429, P < 0.05). And the performance of both two ANN models was significantly better than that of STOP-BANG score (both P < 0.05). The Airway-ANN model was deployed to the cloud (http://njfh-yxb.com.cn:2022/airway_ann).

Conclusion

Our online interpretable Airway-ANN model achieved satisfying ability in identifying the hypoxemia risk in adult (18-64) patients undergoing EGD.

Remimazolam tosilate compared with propofol for gastrointestinal endoscopy in elderly patients: a prospective, randomized and controlled study

Background

Remimazolam tosilate (HR7056, RT), a novel ultrashort-acting benzodiazepine, can be used for procedural sedation and general anaesthesia. However, few studies have focused on the sedative effect of RT during gastrointestinal endoscopy in elderly patients. The purpose of this study is to compare the sedative effect of RT and propofol for gastrointestinal endoscopy in elderly patients.

Methods

A total of 82 patients aged ≥65 years with an American Society of Anaesthesiologists (ASA) grade I-II and a body mass index (BMI) of 18.0 to 30.0 kg/m² who were scheduled for gastrointestinal endoscopy from Jan 2021 to Aug 2021 were selected and randomly divided into a RT group and a propofol group. Alfentanil 5 μg/kg was used for analgesia in both groups. The RT group was given remimazolam tosilate 0.15 mg/kg with supplemental doses of 0.05 mg/kg as need, while the propofol group was given propofol 1.5 mg/kg with supplemental doses of 0.5 mg/kg. The supplemental doses were determined by the modified observational alertness/sedation assessment (MOAA/S) score and the patients’ body movements. Sedative effects, such as the time to loss of consciousness (LOC) (MOAA/S score ≤ 1), successful sedation in one dose, number of supplemental doses after successful induction, and recovery time, were evaluated. Sedation-related side effects, such as injection pain, haemodynamic events and respiratory depression, were also noted. Postoperative nausea and vomiting (PONV), visual analogue scale (VAS) scores at rest, remedial analgesics, and dizziness or headache were recorded. In addition, patients’ satisfaction and physician’s satisfaction of the procedure were compared between the two groups.

Results

Data from 77 patients were analysed. The success rate of sedation in both groups was 100%. The time to LOC (MOAA/S score ≤ 1) in the RT group was longer than that in the propofol group (20.7 ± 6.1s vs. 13.2 ± 5.2s, P < 0.001). There were fewer patients in the RT group reporting injection pain than that in the propofol group (0/39 vs. 5/38, P = 0.025). Haemodynamic events and respiratory depression in the RT group were less frequent than those in the propofol group ((6/39 vs. 17/38, P = 0.005), (2/39 vs. 9/38, P = 0.026), respectively). The number of supplemental doses after successful induction in the RT group was greater than that in the propofol group (4/9/11/13/1/1 vs. 8/4/18/6/2/0 requiring 0, 1, 2, 3, 4 or 5 supplemental doses, P = 0.014). The characteristics of the patients enrolled, postoperative parameters of the patients, and patients’ and physician’s satisfaction of the procedure were comparable in the two groups.

Conclusions

Compared with propofol, RT can be safely and effectively used for gastrointestinal endoscopy sedation in elderly patients, and the incidence of sedation-related adverse reactions, especially haemodynamic events and respiratory depression, is lower. When RT is used, the number of supplemental doses after successful induction may increase slightly.

Trial registration

Chictr.org.cn ChiCTR2000040498. Retrospectively registered (date of registration: December 1, 2020).

Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe?

Percutaneous endoscopic gastrostomy (PEG) is an established practice for long-term nutrition in dysphagia-suffering stroke patients. This study sought to determine the feasibility and safety of outpatient, unsedated PEG implementation in stroke patients. This retrospective cohort study involved stroke victims who underwent unsedated outpatient PEG insertion from 2014 to 2017 at our Surgical Endoscopy Unit. Patients were given pharyngeal anesthesia with lidocaine 10% spray, while the PEG tube was placed under local anesthesia. The incidence of intraprocedural and postprocedural complications and 30-day mortality rate were recorded. Data from 127 cases were analyzed. The procedures were performed with minor, transient complications, which resolved after rescue maneuvers. No intraprocedural and postprocedural major complications or death were observed. During the 30-day follow-up, the most important complication involved a single case of accidental PEG removal that was successfully resolved surgically. Unsedated PEG insertion appears to be a feasible, well-tolerated, and safe option for stroke-related dysphagia.

Prevalence of Precancerous Conditions and Gastric Cancer Based upon the National Cancer Screening Program in Korea for 7 Years, Single Center Experience

Aims. Gastric cancer is the second most prevalent cancer and the third leading cause of cancer-related deaths in Korea. The National Cancer Screening Program (NCSP) has implemented esophagogastroduodenoscopy (EGD) biennially for all Koreans starting in their 40s. This study was conducted to estimate the clinical relevance of NCSP through identifying the prevalence of gastric disease, including cancer. Materials and Methods. Data from 40,821 subjects who received the screening EGD in the single center for 7 years were retrospectively investigated. Results. The overall prevalence of nonatrophic/atrophic/metaplastic gastritis, peptic ulcer, adenoma, early gastric cancer (EGC), and advanced gastric cancer (AGC) was 44.28%, 27.97%, 14.95%, 0.59%, 0.43%, 0.21%, and 0.09%, respectively. The prevalence of metaplastic gastritis, peptic ulcer, adenoma, EGC, and AGC was significantly higher in men than in women. The prevalence of preneoplastic/neoplastic disease significantly increased with age. Judged from the ratio of EGC to AGC, the proportion of EGC made up to 70% of all cancers. Conclusions. Screening endoscopy starting for people in their 40s should be strongly recommended for the elderly. Through the NCSP, the early detection of gastric cancer might contribute to the decreased mortality rate due to gastric cancer in Korea.

Gastrointestinal drug interactions affecting the elderly

With the burgeoning elderly population in the United States, drug interactions are an increasing concern because of altered drug metabolism associated with age and polypharmacy. This article describes interactions between drugs used in common gastrointestinal diseases, including acid peptic disease, diarrhea, constipation, endoscopic procedural sedation, and inflammatory bowel disease, and those used to treat 5 common geriatric primary care diseases: hypertension, diabetes, hyperlipidemia, arthritis, and psychiatric illnesses.

Long-term follow-up of therapeutic ERCP in 78 patients aged 90 years or older

This study aimed to determine the performance and long-term outcomes of therapeutic ERCP in very old patients. Patients aged or over 90 (Group A, n = 78) and consecutive sex-matched controls (Group B, n = 312) under 65 selected were compared. More patients in Group A had chronic concomitant diseases, but the success and complication rates were comparable. The follow-up of 61 patients (78.2%) in Group A were done, with a mean period of 27.5 (3–54) months. Seven patients survived; the main causes of death for the other patients were concomitant diseases (n = 43) and primary diseases (n = 11). In patients with choledocholithiasis, cases with complete extractions of stones in bile ducts survived longer than those without (30 vs. 24 months, P < 0.001). Therapeutic ERCP in patients aged 90 years or older is effective and safe. In patients with choledocholithiasis, complete clearance of stones is associated with longer survival time.

Endoscopy in the elderly

With increasing age, the incidence of both benign and malignant gastrointestinal (GI) disease rises. Endoscopic procedures are commonly performed in elderly and very elderly patients to diagnose and treat GI disorders. There are a number of issues to contemplate when considering performing an endoscopic procedure in an elderly patient, including the anticipated benefits of endoscopy as well as the increased risks associated with procedural sedation and some endoscopic procedures. This review will focus on the yield and safety of endoscopic procedures in older adults.

STOP questionnaire to screen for hypoxemia in deep sedation for young and middle-aged colonoscopy

BACKGROUND AND AIM

Hypoxemia is the most common unexpected cardiopulmonary complication that is used as a surrogate for severe complications in colonoscopy. The aim of the present study was to access the STOP Questionnaire to screen for hypoxemia in deep sedation for colonoscopy in young and middle-aged outpatients.

METHODS

Outpatients aged 18-65 with ASA class I or II who were to undergo elective colonoscopy with deep sedation were offered participation. Before sedation, the patients were given the STOP Questionnaire, a brief survey that stratifies patients into high or low risk of hypoxemia. Data on pulse oxygen saturation (SpO(2) ) were collected during sedation. Hypoxemia was defined as SpO(2)<95% anytime during the procedure, regardless of episode duration. We estimated the score of the STOP Questionnaire and the incidence of hypoxemia.

RESULTS

A total of 210 consecutive outpatients were offered enrollment. Thirteen (6.2%) patients had hypoxemia. Thirty-two (15.2%) patients were scored to be at high risk of hypoxemia, of whom 10 had hypoxemia. Results of analyzing the STOP Questionnaire for the incidence of hypoxemia were sensitivity 76.9%, specificity 88.8%, Youden's index 0.658, consistency rate 88%, kappa value 0.39, positive predictive value 31.3%, negative predictive value 98.3%, and area under receiver operating characteristic (ROC) curve 0.935 (P<0.001, 95% CI 0.879-0.991).

CONCLUSIONS

STOP Questionnaire is a validated and easy-to-use screening tool for hypoxemia in outpatient colonoscopy. It has high sensitivity, specificity and negative predictive value.

Colorectal endoscopic submucosal dissection for elderly patients at least 80 years of age

BACKGROUND

Endoscopic submucosal dissection (ESD) has been used recently for successful en bloc resection of even large lesions, although no consensus appears in medical literature concerning its application to elderly patients. This prospective cohort study aimed to evaluate the efficacy and safety of colorectal ESD for patients 80 years of age or older.

METHODS

Colorectal ESD procedure findings were compared with clinical outcomes, including associated complications and mortalities, for two age groups totaling 196 consecutive patients with 202 colorectal lesions. Of the 196 patients, 31 patients (16%) were 80 years of age or older (group E), and 165 patients (84%) were younger than 80 years (group Y).

RESULTS

The median ages were 82 years in group E and 68 years in group Y. The frequency of chronic concomitant diseases was significantly higher in group E (65%) than in group Y (27%) (p = 0.003). No significant pressure decrease or need for oxygenation was observed in either group. In addition, groups E and Y did not differ significantly in terms of mean lesion sizes (40.9 vs. 39.7 mm) en bloc resection rates (84% vs. 93%), curative rates (78% vs. 84%), median procedure times (65 vs. 70 min), or associated complications (no perforation or delayed bleeding cases [0%] vs. 5 perforations [3%]) The median postprocedure hospitalization period was 3 days in both groups. Except for 10 cases requiring subsequent lymph node dissection surgery, follow-up colonoscopy examinations showed no recurrences or ESD-related mortalities in either group.

CONCLUSION

Colorectal ESD is a safe and effective treatment for elderly patients (age ≥ 80 years) despite a significantly higher frequency of chronic concomitant diseases than among younger patients.