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Azancot S, Dray X, Moshiri P, Soualy A, Guilloux A, Michel PA, Boffa JJ, Becq A. Gastrointestinal Angiectasia in patients with chronic kidney disease: A matched case-control study. Clin Res Hepatol Gastroenterol 2024; 48:102454. [PMID: 39179202 DOI: 10.1016/j.clinre.2024.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND AND STUDY AIMS Chronic kidney disease (CKD) is a well-known risk factor of gastrointestinal angiectasia (GIA). The aim was to compare this population with CDK patients without GIA. METHODS Patients followed in the Nephrology Department of Tenon Hospital for which an endoscopy was performed between 2012 and 2022 were identified. Those with at least one GIA lesion were included ("GIA+" group). A matched control group for age, sex and GFR stage of patients with CKD and no GIA lesion ("GIA-" group) was constituted. A subgroup analysis compared patients with (SB+) and without (SB-) small-bowel involvement. RESULTS A total of 55 patients were included in the GIA+ group. 36.3 % (n = 20) were active smokers and 29.1 % (n = 16) had peripheral arterial disease versus 16.4 % (n = 9) (OR 2.89, p = 0.03), and 9.1 % (n = 5) (OR 4.05, p = 0.015) in the GIA- group. Thirteen patients (23.6 %) had a SB lesion. Duodenal involvement was present in 69.2 % of cases in the SB+ group versus 28.6 % in the SB- group (p = 0.02). Median number of endoscopies, hemostatic technics and hospitalizations was 7, 3 and 6, versus 2 (p = 0.0001), 1 (p = 0.001) and 1 (p = 0.0002) in the SB- group. CONCLUSIONS CKD patients with GIA had a greater cardiovascular risk with a higher incidence of vascular nephropathy. Small-bowel GIA were associated with a higher morbidity.
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Affiliation(s)
- Sarah Azancot
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France
| | - Xavier Dray
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Adil Soualy
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France
| | - Antoine Guilloux
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Jean Jacques Boffa
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France; Sorbonne University, INSERM U1155 CORAKID, Paris, France
| | - Aymeric Becq
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France.
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Chang W, Zhang Z, Jia B, Ding K, Pan Z, Su G, Zhang W, Liu T, Zhong Y, He G, Ren L, Wei Y, Li D, Cui X, Yang J, Shi Y, Bissonnette M, He C, Zhang W, Fan J, Xu J. A 5-Hydroxymethylcytosine-Based Noninvasive Model for Early Detection of Colorectal Carcinomas and Advanced Adenomas: The METHOD-2 Study. Clin Cancer Res 2024; 30:3337-3348. [PMID: 38814264 DOI: 10.1158/1078-0432.ccr-24-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/19/2024] [Accepted: 05/24/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Detection of colorectal carcinomas at a time when there are more treatment options is associated with better outcomes. This prospective case-control study assessed the 5-hydroxymethylcytosine (5hmC) biomarkers in circulating cell-free DNA (cfDNA) for early detection of colorectal carcinoma and advanced adenomas (AA). EXPERIMENTAL DESIGN Plasma cfDNA samples from 2,576 study participants from the multicenter METHOD-2 study (NCT03676075) were collected, comprising patients with newly diagnosed colorectal carcinoma (n = 1,074), AA (n = 356), other solid tumors (n = 80), and non-colorectal carcinoma/AA controls (n = 1,066), followed by genome-wide 5hmC profiling using the 5hmC-Seal technique and the next-generation sequencing. A weighted diagnostic model for colorectal carcinoma (stage I-III) and AA was developed using the elastic net regularization in a discovery set and validated in independent samples. RESULTS Distribution of 5hmC in cfDNA reflected gene regulatory relevance and tissue of origin. Besides being confirmed in internal validation, a 96-gene model achieved an area under the curve (AUC) of 90.7% for distinguishing stage I-III colorectal carcinoma from controls in 321 samples from multiple centers for external validation, regardless of primary location or mutation status. This model also showed cancer-type specificity as well as high capacity for distinguishing AA from controls with an AUC of 78.6%. Functionally, differential 5hmC features associated with colorectal carcinoma and AA demonstrated relevance to colorectal carcinoma biology, including pathways such as calcium and MAPK signaling. CONCLUSIONS Genome-wide mapping of 5hmC in cfDNA shows promise as a highly sensitive and specific noninvasive blood test to be integrated into screening programs for improving early detection of colorectal carcinoma and high-risk AA.
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Affiliation(s)
- Wenju Chang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
- Department of General Surgery, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, China
| | - Zhou Zhang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Baoqing Jia
- Department of General Surgery Hospital, The 301 Hospital, Beijing, China
| | - Kefeng Ding
- Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cancer Center, Zhejiang University, Hangzhou, China
| | - Zhizhong Pan
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guoqiang Su
- Department of Colorectal Surgery, Xiamen Cancer Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Tianyu Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Yunshi Zhong
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of General Surgery, Xuhui Hospital, Fudan University, Shanghai, China
| | - Guodong He
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Li Ren
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Dongdong Li
- Shanghai Epican Genetech Co., Ltd., Shanghai, China
| | - Xiaolong Cui
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Chemistry, The University of Chicago, Chicago, Illinois
| | - Jun Yang
- Bionova (Shanghai) MedTech Co., Ltd., Shanghai, China
| | - Yixiang Shi
- Bionova (Shanghai) MedTech Co., Ltd., Shanghai, China
| | - Marc Bissonnette
- Department of Medicine and The University of Chicago Comprehensive Cancer Center, The University of Chicago, Chicago, Illinois
| | - Chuan He
- Department of Chemistry, The University of Chicago, Chicago, Illinois
- Department of Biochemistry and Molecular Biology, and Institute for Biophysical Dynamics, The University of Chicago, Chicago, Illinois
- The Howard Hughes Medical Institute, The University of Chicago, Chicago, Illinois
| | - Wei Zhang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jia Fan
- Department of Liver Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianmin Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
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Austin K, Deiss-Yehiely N, Alexander JT. Diagnosis and Management of Celiac Disease. JAMA 2024; 332:249-250. [PMID: 38922595 DOI: 10.1001/jama.2024.5883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
This JAMA Clinical Guidelines Synopsis summarizes the American College of Gastroenterology’s 2023 guideline update on diagnosis and management of celiac disease.
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Affiliation(s)
- Kerstin Austin
- Division of Gastroenterology and Hepatology, University of Wisconsin, Madison, Wisconsin
| | - Nimrod Deiss-Yehiely
- Division of Gastroenterology and Hepatology, University of Wisconsin, Madison, Wisconsin
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Walayat S, Stadmeyer P, Hameed A, Sarfaraz M, Estrada P, Benson M, Soni A, Pfau P, Hayes P, Kile B, Cruz T, Gopal D. Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. World J Gastrointest Endosc 2024; 16:413-423. [PMID: 39072249 PMCID: PMC11271719 DOI: 10.4253/wjge.v16.i7.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/22/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. AIM To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Illinois, Peoria, IL 61605, United States
| | - Peter Stadmeyer
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53792, United States
| | - Azfar Hameed
- Department of Internal Medicine, Texas Health Denton, Denton, TX 76201, United States
| | - Minahil Sarfaraz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore 042, Pakistan
| | - Paul Estrada
- Department of Gastroenterology, Texas Tech University Health Services Center, El Paso, TX 79911, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Paul Hayes
- Finance Business Partners UW Health, University of Wisconsin, Madison, WI 53792, United States
| | - Brittney Kile
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Toni Cruz
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Edelson JC, Rockey DC. Safety of Endoscopy in Cirrhosis. Dig Dis Sci 2024:10.1007/s10620-024-08539-x. [PMID: 38977523 DOI: 10.1007/s10620-024-08539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Endoscopic procedures are among the most commonly performed medical procedures and the serious adverse event rate is reported to be 1-3 adverse events per 1000 procedures. AIMS Here, we have examined the safety of endoscopy specifically in cirrhotic populations. METHODS We conducted a retrospective case (cirrhosis)-control (non-cirrhosis) study of the outcomes of patients undergoing endoscopy in a large academic medical center. The primary outcome was a procedural or post-procedural complication. Complete clinical data were collected for all patients undergoing endoscopic procedures-including esophagogastroduodenoscopy, colonoscopy, EUS, ERCP, flexible sigmoidoscopy, and others. Cirrhosis was carefully defined based on clinico-pathological grounds. RESULTS We identified 16,779 patients who underwent endoscopy, including 2618 with cirrhosis and 14,161 without cirrhosis. There were 167 complications (0.99%), which included 15/2618 cirrhotics (0.6%) and 152/14,161 (1.1%) non-cirrhotics. The most common complications were cardiopulmonary (including hypotension and hypoxemia) found in 67% of patients; procedurally related complications occurred in 19% of patients. The complication rate was the same or lower in cirrhotics than controls undergoing esophagogastroduodenoscopy (0.6% vs 0.9%, p = 0.03), colonoscopy (0.6% vs. 0.6%, p = NS), or ERCP (0.7% vs. 1.4%, p = NS) Logistic regression analysis identified the following features to be associated with an increased risk of having a complication: inpatient status, history of myocardial infarction, and an EUS procedure. CONCLUSIONS Endoscopy in cirrhotic patients was as safe or safer than non-cirrhotic patients undergoing similar procedures.
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Affiliation(s)
- Jerome C Edelson
- Division of Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Don C Rockey
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA.
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC, USA.
- Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC, 29425, USA.
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Patel H, Radadiya D. Estimating the Penalties of Cytopenias Pre-endoscopy: Is Enough Known? Dig Dis Sci 2024; 69:2287-2288. [PMID: 38739231 DOI: 10.1007/s10620-024-08461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Harsh Patel
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Dhruvil Radadiya
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA.
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Matsubayashi CO, Cheng S, Hulchafo I, Zhang Y, Tada T, Buxbaum JL, Ochiai K. Artificial intelligence for gastric cancer in endoscopy: From diagnostic reasoning to market. Dig Liver Dis 2024; 56:1156-1163. [PMID: 38763796 DOI: 10.1016/j.dld.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/21/2024]
Abstract
Recognition of gastric conditions during endoscopy exams, including gastric cancer, usually requires specialized training and a long learning curve. Besides that, the interobserver variability is frequently high due to the different morphological characteristics of the lesions and grades of mucosal inflammation. In this sense, artificial intelligence tools based on deep learning models have been developed to support physicians to detect, classify, and predict gastric lesions more efficiently. Even though a growing number of studies exists in the literature, there are multiple challenges to bring a model to practice in this field, such as the need for more robust validation studies and regulatory hurdles. Therefore, the aim of this review is to provide a comprehensive assessment of the current use of artificial intelligence applied to endoscopic imaging to evaluate gastric precancerous and cancerous lesions and the barriers to widespread implementation of this technology in clinical routine.
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Affiliation(s)
- Carolina Ogawa Matsubayashi
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, University of São Paulo, São Paulo, Brasil; AI Medical Service Inc., Tokyo, Japan.
| | - Shuyan Cheng
- Department of Population Health Science, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ismael Hulchafo
- Columbia University School of Nursing, New York, NY 10032, USA
| | - Yifan Zhang
- Department of Population Health Science, Weill Cornell Medical College, New York, NY 10065, USA
| | - Tomohiro Tada
- AI Medical Service Inc., Tokyo, Japan; Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Kentaro Ochiai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Menon S, Norman R, Iyer PG, Ragunath K. Stratification of Barrett's esophagus surveillance based on p53 immunohistochemistry: a cost-effectiveness analysis by an international collaborative group. Endoscopy 2024. [PMID: 38698618 DOI: 10.1055/a-2317-8184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Surveillance of nondysplastic Barrett's esophagus (NDBE) is recommended to identify progression to dysplasia; however, the most cost-effective strategy remains unclear. Mutation of TP53 or aberrant expression of p53 have been associated with the development of dysplasia in BE. We sought to determine if surveillance intervals for BE could be stratified based on p53 expression. METHODS A Markov model was developed for NDBE. Patients with NDBE underwent p53 immunohistochemistry (IHC) and those with abnormal p53 expression underwent surveillance endoscopy at 1 year, while patients with normal p53 expression underwent surveillance in 3 years. Patients with dysplasia underwent endoscopic therapy and surveillance. RESULTS On base-case analysis, the strategy of stratifying surveillance based on abnormal p53 IHC was cost-effective relative to conventional surveillance and a natural history model, with an incremental cost-effectiveness ratio (ICER) of $8258 for p53 IHC-based surveillance. Both the conventional and p53-stratified surveillance strategies dominated the natural history model. On probabilistic sensitivity analysis, the p53 IHC strategy ($28 652; 16.78 quality-adjusted life years [QALYs]) was more cost-effective than conventional surveillance ($25 679; 16.17 QALYs) with a net monetary benefit of $306 873 compared with conventional surveillance ($297 642), with an ICER <$50 000 in 96% of iterations. The p53-stratification strategy was associated with a 14% reduction in the overall endoscopy burden and a 59% increase in dysplasia detection. CONCLUSION A surveillance strategy for BE based on abnormal p53 IHC is cost-effective relative to a conventional surveillance strategy and is likely to be associated with higher rates of dysplasia diagnosis.
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Affiliation(s)
- Shyam Menon
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom of Great Britain and Northern Ireland
| | - Richard Norman
- Health Economist, School of Population Health, Curtin University, Perth, Australia
| | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | - Krish Ragunath
- Curtin Medical School, Curtin University, Perth, Australia
- Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Australia
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Chuah JS, Tan JH, Bujang MA, Chan KK, Kosai NR. Transcutaneous electric nerve stimulation of acupuncture points improves tolerance in adults undergoing diagnostic upper gastrointestinal endoscopy: a single-center, double-blinded, randomized controlled trial. Surg Endosc 2024; 38:3279-3287. [PMID: 38658388 DOI: 10.1007/s00464-024-10841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Oesophagogastroduodenoscopy (OGDS) is the most common diagnostic procedure for upper gastrointestinal diseases. It often causes discomfort and anxiety, which are only mitigated by systemic sedation. However, sedation poses additional risks of adverse cardiopulmonary events, increased medical costs, and prolonged recovery. Transcutaneous electrical nerve stimulation of acupuncture points (Acu-TENS) is a non-invasive and innovative approach that induces analgesic effect during endoscopy. This trial is the first to be reported in English that explores the potential of Acu-TENS to increase patient tolerance during non-sedated elective diagnostic OGDS. METHODS A double-blinded randomized controlled trial involving 348 subjects was conducted at a tertiary hospital to evaluate the success rate of OGDS with Acu-TENS. Subjects aged 18-75 years scheduled for their first elective diagnostic OGDS were randomized into the intervention (Acu-TENS) and placebo arms. OGDS success was assessed based on subjects' satisfaction ratings on a Likert scale and procedure's technical adequacy. Secondary measures included subjects' willingness to undergo future OGDS under similar conditions, procedure duration, and the endoscopist's perceived ease of the procedure. RESULTS OGDS success rates were significantly higher with Acu-TENS (77.8%) than with the placebo (68.0%; odds ratio [OR] 1.64, 95% confidence interval [CI] 1.01-2.66, p = 0.043). Subjects who received Acu-TENS expressed higher willingness for future OGDS (78.9%) than those who received the placebo (68.6%; OR 1.71, 95% CI 1.04-2.79, p = 0.031). Procedure duration were significantly shorter in the intervention arm (6.0 min) than in the placebo arm (10.0 min; p = 0.002). No adverse effects were reported, and endoscopists perceived similar procedure ease in both arms. CONCLUSIONS Acu-TENS improved OGDS success and enhanced patients' experiences during non-sedated OGDS. It demonstrated safety with no side effects and reduced the procedure completion time. It could be used as an adjunct in non-sedated diagnostic OGDS.
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Affiliation(s)
- Jun Sen Chuah
- Department of General Surgery, Universiti Kebangsaan Malaysia Medical Centre, Cheras, 56000, Kuala Lumpur, Malaysia.
- Department of General Surgery, Hospital Sultanah Aminah Johor Bahru, Ministry of Health Malaysia, Jalan Persiaran Abu Bakar Sultan, 80100, Johor Bahru, Johor, Malaysia.
| | - Jih Huei Tan
- Department of General Surgery, Hospital Sultanah Aminah Johor Bahru, Ministry of Health Malaysia, Jalan Persiaran Abu Bakar Sultan, 80100, Johor Bahru, Johor, Malaysia
| | - Mohamad Adam Bujang
- Clinical Research Centre, Sarawak General Hospital, Kuching, Sarawak, Ministry of Health Malaysia, Kuching, Malaysia
| | - Koon Khee Chan
- Department of General Surgery, Hospital Sultanah Aminah Johor Bahru, Ministry of Health Malaysia, Jalan Persiaran Abu Bakar Sultan, 80100, Johor Bahru, Johor, Malaysia
| | - Nik Ritza Kosai
- Department of General Surgery, Universiti Kebangsaan Malaysia Medical Centre, Cheras, 56000, Kuala Lumpur, Malaysia
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Christensen AK, Egeland C, Bjoern Heje J, Asaad SK, Loprete R, Solstad TU, Kjaer D, Dikinis S, Achiam MP. Assessing the benefits of repeated esophagogastroduodenoscopy at a specialized center before gastric and esophageal cancer surgery. Scand J Surg 2024; 113:98-108. [PMID: 38695549 DOI: 10.1177/14574969241242202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND The surgical treatment of gastric and esophageal cancer in Denmark is centralized in four specialized esophagogastric cancer (EGC) centers. Patients are referred after an esophagogastroduodenoscopy (EGD) at a secondary healthcare facility. The EGD is repeated at the specialized EGC center before determining a surgical treatment strategy. This multicenter retrospective study aimed to investigate the quality of EGDs performed at a secondary healthcare facility and evaluate the clinical value of repeated EGD at a specialized center when determining the surgical treatment strategy. METHODS Patients from three of the four centers, who underwent esophagectomy or gastrectomy with curative intent from 1 June 2016 to 1 May 2021, were included. EGD reports from the referral facilities and EGC centers were compared based on a predefined checklist. Furthermore, endoscopist experience, the time between examinations, and histology were registered. Finally, it was assessed whether the specialized EGD led to any substantial changes in surgical treatment. Baseline characteristics and differences in EGD reports were described and McNemar's chi-square test was performed. A logistic regression analysis was conducted to identify risk factors for a change in surgical strategy. RESULTS The study included 953 patients who underwent both an initial EGD and EGD at referral to a specialized center. In 644 cases (68%), the information from the initial EGD was considered insufficient concerning preoperative tumor information. In 113 (12%) cases, the findings in the specialized EGD would lead to a significant alteration in the surgical strategy compared with the primary EGD. CONCLUSION The findings suggest that repeated EGD at a specialized center is of clinical value and helps ensure proper surgical treatment for patients undergoing curative surgery for gastroesophageal cancer.
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Affiliation(s)
- Astrid Kolind Christensen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9 Copenhagen 2100 Denmark
| | - Charlotte Egeland
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Bjoern Heje
- Department of Gastrointestinal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Sofia Kamakh Asaad
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Roberto Loprete
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trygve Ulvund Solstad
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kjaer
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Sarunas Dikinis
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Michael P Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Aby ES, Eckmann JD, Abimansour J, Katzka DA, Beveridge C, Triggs JR, Dbouk M, Abdi T, Turner KO, Antunes C, Zhuo J, Kamal AN, Patel P, Gyawali CP, Sloan JA. Esophageal Lichen Planus: A Descriptive Multicenter Report. J Clin Gastroenterol 2024; 58:427-431. [PMID: 37436831 PMCID: PMC10994181 DOI: 10.1097/mcg.0000000000001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
GOALS To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). BACKGROUND ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. STUDY A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. RESULTS Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. CONCLUSIONS Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.
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Affiliation(s)
- Elizabeth S. Aby
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
| | - Jason D. Eckmann
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
| | - Jad Abimansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Claire Beveridge
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tsion Abdi
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin O. Turner
- Department of Pathology, University of Minnesota, Minneapolis
| | - Catiele Antunes
- Division of Digestive Disease and Nutrition, University of Oklahoma, Oklahoma City, OK
| | - Justin Zhuo
- Department of Medicine, Division of Gastroenterology, Stanford University, Stanford, CA
| | - Afrin N. Kamal
- Department of Medicine, Division of Gastroenterology, Stanford University, Stanford, CA
| | - Parth Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Joshua A. Sloan
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
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12
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Redd WD, McCallen JD, Xue Z, Kiran A, Barlowe TS, Reed CC, Eluri S, Dellon ES. Association between time from esophageal food impaction to endoscopy and adverse events. Gastrointest Endosc 2024; 99:525-536.e3. [PMID: 37951280 PMCID: PMC10954388 DOI: 10.1016/j.gie.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND AND AIMS Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events. METHODS In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events. RESULTS Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders. CONCLUSIONS Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.
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Affiliation(s)
- Walker D. Redd
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Justin D. McCallen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Akshatha Kiran
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Trevor S. Barlowe
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
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13
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Mohapatra A, Mohapatra S, Mahawar S, Pani KC, Mohapatra N, Ramchandani M, Reddy N, Goenka MK, Uedo N. Endoscopic diagnosis and prevalence of early gastric cancer in India: A prospective study. DEN OPEN 2024; 4:e309. [PMID: 37927951 PMCID: PMC10625177 DOI: 10.1002/deo2.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/25/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
Objectives Although countries like Japan and South Korea have implemented nationwide endoscopic screening programs, there is limited evidence on the effectiveness of endoscopy for diagnosing early gastric cancer (EGC) in developing countries such as India. In the present study, we aimed to determine the feasibility of endoscopic detection of EGC from India. Methods The data was prospectively collected for all patients ≥40 years who underwent a diagnostic upper endoscopy from April to September 2021. A single endoscopist who performed the endoscopic procedures completed 1-month training in advanced endoscopy in Japan. Following the training, the endoscopist continued to engage in internet-based discussions regarding his cases encountered. Prior to this training, the endoscopist had not detected any EGC cases during his 12-year gastroenterology practice. Results A total of 1033 patients were included in the study, with males accounting for 65.4% and a mean age 52 years. The average procedural time was 7.13 ± 4.8 min. A total of 25 patients (2.4%) were found to have GC, including 6 patients (0.6%) with EGC. Two patients had synchronous EGC lesions. All EGC patients were males, with an average age of 66 years. All EGCs were detected in the distal stomach in the presence of Helicobacter pylori infection and severe atrophic gastritis. Conclusion Our findings showed that the endoscopic detection of EGC is feasible in India. Optimal training on endoscopic diagnosis of EGC can improve the detection of such lesion. Further studies are warranted to assess the optimization and implementation of an endoscopic screening program for EGC in India.
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Affiliation(s)
- Ashutosh Mohapatra
- Department of Gastroenterology and HepatologySai Institute of Gastroenterology and Liver SciencesBhubaneswarIndia
| | | | - Shruti Mahawar
- Department of PathologyGenx Diagnostic CenterBhubaneswarIndia
| | | | | | - Mohan Ramchandani
- Department of Gastroenterology and HepatologyAsian Institute of GastroenterologyHyderabadIndia
| | - Nageshwar Reddy
- Department of Gastroenterology and HepatologyAsian Institute of GastroenterologyHyderabadIndia
| | - Mahesh K. Goenka
- Department of Gastroenterology and HepatologyApollo Gleneagles HospitalsKolkataIndia
| | - Noriya Uedo
- Department of Gastroenterology and HepatologyOsaka International Cancer InstituteOsakaJapan
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14
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Vu Trung K, Heise C, Abou-Ali E, Auriemma F, Karam E, van der Wiel SE, Bruno MJ, Caillol F, Giovannini M, Masaryk V, Will U, Anderloni A, Pérez-Cuadrado-Robles E, Dugic A, Meier B, Paik WH, Petrone MC, Wichmann D, Dinis-Ribeiro M, Gonçalves TC, Wedi E, Schmidt A, Gulla A, Hoffmeister A, Rosendahl J, Ratone JP, Saadeh R, Repici A, Deprez P, Sauvanet A, Souche FR, Fabre JM, Muehldorfer S, Caca K, Löhr M, Michl P, Krug S, Regner S, Gaujoux S, Hollenbach M. Endoscopic papillectomy for ampullary lesions of minor papilla. Gastrointest Endosc 2024; 99:587-595.e1. [PMID: 37951279 DOI: 10.1016/j.gie.2023.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND AND AIMS Ampullary lesions (ALs) of the minor duodenal papilla are extremely rare. Endoscopic papillectomy (EP) is a routinely used treatment for AL of the major duodenal papilla, but the role of EP for minor AL has not been accurately studied. METHODS We identified 20 patients with ALs of minor duodenal papilla in the multicentric database from the Endoscopic Papillectomy vs Surgical Ampullectomy vs Pancreatitcoduodenectomy for Ampullary Neoplasm study, which included 1422 EPs. We used propensity score matching (nearest-neighbor method) to match these cases with ALs of the major duodenal papilla based on age, sex, histologic subtype, and size of the lesion in a 1:2 ratio. Cohorts were compared by means of chi-square or Fisher exact test as well as Mann-Whitney U test. RESULTS Propensity score-based matching identified a cohort of 60 (minor papilla 20, major papilla 40) patients with similar baseline characteristics. The most common histologic subtype of lesions of minor papilla was an ampullary adenoma in 12 patients (3 low-grade dysplasia and 9 high-grade dysplasia). Five patients revealed nonneoplastic lesions. Invasive cancer (T1a), adenomyoma, and neuroendocrine neoplasia were each found in 1 case. The rate of complete resection, en-bloc resection, and recurrences were similar between the groups. There were no severe adverse events after EP of lesions of minor papilla. One patient had delayed bleeding that could be treated by endoscopic hemostasis, and 2 patients showed a recurrence in surveillance endoscopy after a median follow-up of 21 months (interquartile range, 12-50 months). CONCLUSIONS EP is safe and effective in ALs of the minor duodenal papilla. Such lesions could be managed according to guidelines for EP of major duodenal papilla.
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Affiliation(s)
- Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian Heise
- Medical Department I, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Einas Abou-Ali
- Department of Gastroenterology, Digestive Oncology, and Endoscopy, Cochin Hospital, Paris Descartes University, Paris, France
| | - Francesco Auriemma
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Elias Karam
- Department of Digestive Surgery, INSERM U1086 ANTICIPE, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - Sophia E van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Fabrice Caillol
- Department of Endoscopy, Institut Paoli Calmettes, Marseille, France
| | - Marc Giovannini
- Department of Endoscopy, Institut Paoli Calmettes, Marseille, France
| | - Viliam Masaryk
- Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany
| | - Uwe Will
- Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Enrique Pérez-Cuadrado-Robles
- Interventional Endoscopy, Department of Gastroenterology, Hôpital Européen Georges-Pompidou, Paris, France; Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Ana Dugic
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Benjamin Meier
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes, and Infectious Diseases, RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Woo H Paik
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Maria C Petrone
- Endosonography Unit, Pancreatobiliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Dörte Wichmann
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Instituto Português de Oncologia do Porto, Porto, Portugal; RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto/Porto Comprehensive Cancer Center, Porto, Portugal; Department of Community Medicine, Health Information, and Decision, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tiago C Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal; School of Medicine, University of Minho, Braga/Guimarães, Portugal; PT Government Associate Laboratory, ICVS/3B, Braga/Guimarães, Portugal
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medicine Göttingen, Göttingen, Germany; Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Arthur Schmidt
- Department of Medicine II, University of Freiburg Medical Center, Freiburg, Germany
| | - Aiste Gulla
- Department of Surgery, Lithuanian University of Health Sciences, Santaros Klinikos, Kaunas, Lithuania; General Surgery, MedStar Georgetown University Hospital, John Hopkins University, Washington, DC, USA
| | - Albrecht Hoffmeister
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Jonas Rosendahl
- Medical Department I, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Rita Saadeh
- Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pierre Deprez
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes, and Infectious Diseases, RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Alain Sauvanet
- Department of Digestive Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Francois R Souche
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Jean M Fabre
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Steffen Muehldorfer
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Karel Caca
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes, and Infectious Diseases, RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrick Michl
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Krug
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Sara Regner
- Section for Surgery, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Sebastien Gaujoux
- Department of Pancreatic and Endocrine Surgery, Pitié-Salpetriere Hospital, Médecine Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany; Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
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15
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Patel J, Sohal A, Chaudhry H, Kalra S, Kohli I, Singh I, Dukovic D, Yang J. Predictors and impact of aspiration pneumonia in patients undergoing esophagogastroduodenoscopy: national inpatient sample 2016-2020. Eur J Gastroenterol Hepatol 2024; 36:298-305. [PMID: 38179867 DOI: 10.1097/meg.0000000000002698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Aspiration pneumonia is a rare but feared complication among patients undergoing esophagogastroduodenoscopy (EGD). Our study aims to assess the incidence as well as risk factors for aspiration pneumonia in patients undergoing EGD. METHODS National Inpatient Sample 2016-2020 was used to identify adult patients undergoing EGD. Patients were stratified into two groups based on the presence of aspiration pneumonia. Multivariate logistic regression analysis was performed to identify the risk factors associated with aspiration pneumonia. We adjusted for patient demographics, Elixhauser comorbidities and hospital characteristics. RESULTS Of the 1.8 million patients undergoing EGD, 1.9% of the patients developed aspiration pneumonia. Patients with aspiration pneumonia were mostly males (59.54%), aged >65 years old (66.19%), White (72.2%), had Medicare insurance (70.5%) and were in the lowest income quartile (28.7%). On multivariate analysis, the age >65 group, White race, congestive heart failure (CHF), neurological disorders and chronic obstructive pulmonary disease were associated with higher odds of aspiration pneumonia. This complication was associated with higher in-hospital mortality (9% vs. 0.8%; P < 0.001) and longer length of stay (10.54 days vs. 4.85 days; P < 0.001). CONCLUSION Our study found that rates of post-EGD aspiration pneumonia are increasing. We found a significant association between various comorbidities and aspiration pneumonia. Our data suggests that we need to optimize these patients before EGD, as the development of aspiration is associated with worsened outcomes. Further prospective studies are needed to clarify these associations.
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Affiliation(s)
- Jay Patel
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, Seattle, Washington
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco-Fresno, California, USA
| | - Shivam Kalra
- Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Isha Kohli
- Department of Graduate Public Health, Icahn School of Medicine, Mount Sinai, New York
| | - Ishandeep Singh
- Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dino Dukovic
- Department of Internal Medicine, Ross University School of Medicine, Bridgetown, Barbados
| | - Juliana Yang
- Department of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, Texas, USA
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Sakulsaengprapha V, Masterson JP, Rifkin SB, Mathews SC. A 5-Year Statewide Analysis of Unplanned Hospital Visits for EGD, Colonoscopy, Combined EGD/Colonoscopy, and ERCP. GASTRO HEP ADVANCES 2024; 3:510-518. [PMID: 39131717 PMCID: PMC11307462 DOI: 10.1016/j.gastha.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/29/2024] [Indexed: 08/13/2024]
Abstract
Background and Aims Conventional complication rates for gastrointestinal endoscopic procedures may underestimate the broader risk represented by postprocedure unplanned hospital visits (UHVs). We aimed to characterize UHVs for procedures in Maryland and the District of Columbia from 2014 to 2018. Methods Data for all esophagogastroduodenoscopies (EGDs), colonoscopies, combined EGDs/colonoscopies, and endoscopic retrograde cholangiopancreatographies (ERCPs) performed between 2014 and 2018 was provided by the Maryland Health Information Exchange (Chesapeake Regional Information System for our Patients'). Patient demographics, timing of UHV within 14 days postprocedure, distance traveled, facility site ("home" vs "away" institution), and International Classification of Diseases codes for the UHV were analyzed. Only UHVs potentially attributable to the endoscopic procedures were included. Results Among 304,786 endoscopic procedures and 3904 unplanned visits, the 14-day UHV rates were 1.7%, 0.6%, 1.3%, and 5.2% for EGD, colonoscopy, combined EGD/colonoscopy, and ERCP procedures respectively. From 2014 to 2018, the UHV rate on an annual basis remained stable for all procedure types except for ERCPs which increased. Patients who experienced UHVs were statistically different in sex, race, age, and distance traveled. UHVs most often occurred on postprocedure day 1; emergency department visits occurred most commonly. UHVs for all procedures, except ERCPs, were more likely to occur at a "home" institution. Overall, patients were more likely to be admitted postprocedure at an "away" institution. Conclusion Postendoscopic procedure UHV rates were generally low. However, UHV rates for EGDs and colonoscopies were significantly higher than conventional complication rates. As 30%-60% of all unplanned visits occurred at an "away" institution, endoscopists should consider a broad approach to detecting postprocedure complications and not rely on a single institution for data capture.
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Affiliation(s)
- Vorada Sakulsaengprapha
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Samara B. Rifkin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Simon C. Mathews
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ravindran S, Matharoo M, Rutter MD, Ashrafian H, Darzi A, Healey C, Thomas-Gibson S. Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS). Endoscopy 2024; 56:89-99. [PMID: 37722604 DOI: 10.1055/a-2177-4130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
BACKGROUND Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. METHODS Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. RESULTS From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings. CONCLUSIONS This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.
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Affiliation(s)
- Srivathsan Ravindran
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, United Kingdom of Great Britain and Northern Ireland
- Surgery and Cancer, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Manmeet Matharoo
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Matthew David Rutter
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, United Kingdom of Great Britain and Northern Ireland
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom of Great Britain and Northern Ireland
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Hutan Ashrafian
- Surgery and Cancer, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
- Institute of Global Health Innovation, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Ara Darzi
- Surgery and Cancer, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
- Institute of Global Health Innovation, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Chris Healey
- Gastroenterology, Airedale NHS Foundation Trust, Keighley, United Kingdom of Great Britain and Northern Ireland
| | - Siwan Thomas-Gibson
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, United Kingdom of Great Britain and Northern Ireland
- Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
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Park J, Ghanim R, Rahematpura A, Gerage C, Abramson A. Electromechanical convective drug delivery devices for overcoming diffusion barriers. J Control Release 2024; 366:650-667. [PMID: 38190971 PMCID: PMC10922834 DOI: 10.1016/j.jconrel.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/10/2024]
Abstract
Drug delivery systems which rely on diffusion for mass transport, such as hydrogels and nanoparticles, have enhanced drug targeting and extended delivery profiles to improve health outcomes for patients suffering from diseases including cancer and diabetes. However, diffusion-dependent systems often fail to provide >0.01-1% drug bioavailability when transporting macromolecules across poorly permeable physiological tissues such as the skin, solid tumors, the blood-brain barrier, and the gastrointestinal walls. Convection-enabling robotic ingestibles, wearables, and implantables physically interact with tissue walls to improve bioavailability in these settings by multiple orders of magnitude through convective mass transfer, the process of moving drug molecules via bulk fluid flow. In this Review, we compare diffusive and convective drug delivery systems, highlight engineering techniques that enhance the efficacy of convective devices, and provide examples of synergies between the two methods of drug transport.
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Affiliation(s)
- Jihoon Park
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Ramy Ghanim
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Adwik Rahematpura
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Caroline Gerage
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Alex Abramson
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Sidhu R, Turnbull D, Haboubi H, Leeds JS, Healey C, Hebbar S, Collins P, Jones W, Peerally MF, Brogden S, Neilson LJ, Nayar M, Gath J, Foulkes G, Trudgill NJ, Penman I. British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. Gut 2024; 73:219-245. [PMID: 37816587 PMCID: PMC10850688 DOI: 10.1136/gutjnl-2023-330396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023]
Abstract
Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.
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Affiliation(s)
- Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Turnbull
- Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, UK
| | - Hasan Haboubi
- Department of Gastroenterology, University Hospital Llandough, Llandough, South Glamorgan, UK
- Institute of Life Sciences, Swansea University, Swansea, UK
| | - John S Leeds
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Chris Healey
- Airedale NHS Foundation Trust, Keighley, West Yorkshire, UK
| | - Srisha Hebbar
- Department of Gastroenterology, University Hospital of North Midlands, Stoke-on-Trent, Staffordshire, UK
| | - Paul Collins
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Jones
- Specialist Pharmacist Breastfeeding and Medication, Portsmouth, UK
| | - Mohammad Farhad Peerally
- Digestive Diseases Unit, Kettering General Hospital; Kettering, Kettering, Northamptonshire, UK
- Department of Population Health Sciences, College of Life Science, University of Leicester, Leicester, UK
| | - Sara Brogden
- Department of Gastroenterology, University College London, UK, London, London, UK
| | - Laura J Neilson
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, Tyne and Wear, UK
| | - Manu Nayar
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Jacqui Gath
- Patient Representative on Guideline Development Group and member of Independent Cancer Patients' Voice, Sheffield, UK
| | - Graham Foulkes
- Patient Representative on Guideline Development Group, Manchester, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - Ian Penman
- Centre for Liver and Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, Midlothian, UK
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20
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Patel A, Treves G, Samreen I. The Safety of Endoscopic Procedures in Patients With Thrombocytopenia: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51773. [PMID: 38322081 PMCID: PMC10844715 DOI: 10.7759/cureus.51773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Endoscopic procedures are essential in gastroenterology but pose significant risks for thrombocytopenic patients who have lower platelet counts, increasing the likelihood of bleeding complications. This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess bleeding risks in thrombocytopenic patients undergoing various endoscopic procedures. A comprehensive search was conducted across databases like PubMed, MEDLINE, and EBSCO, using stringent criteria for inclusion and exclusion, with study quality assessed via the Newcastle-Ottawa Scale and thrombocytopenia severity classified by Common Terminology Criteria for Adverse Events (CTCAE) criteria. Statistical analysis focused on bleeding event incidence rates at different platelet count thresholds, utilizing RevMan Web (Cochrane, London, UK) and Excel (Microsoft® Corp., Redmond, WA). The search yielded 1,675 potential articles, but only three retrospective cohort studies were selected. Results showed a significant increase in bleeding risk for patients with platelet counts below 50,000/mm3, particularly under 25,000/mm3, with a 5.5% prevalence of post-procedure bleeding in moderate to severe thrombocytopenic patients versus 4.0% in those with higher counts, and a threefold higher risk in severe thrombocytopenia. The study highlights the need for meticulous pre-procedure assessments in thrombocytopenic patients and points out disparities in guideline recommendations, suggesting personalized approaches based on patient-specific risks. It underscores balancing diagnostic yield against bleeding risks, especially in severe thrombocytopenia, and discusses the controversial role of prophylactic platelet transfusions, advocating for a nuanced approach. In conclusion, this meta-analysis provides critical insights into managing thrombocytopenia in endoscopic procedures, emphasizing the importance of individualized patient assessment and adherence to evolving guidelines, and underlining the necessity of further research to refine these guidelines and improve patient safety and outcomes in this challenging clinical scenario.
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Affiliation(s)
- Akash Patel
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Guy Treves
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Isha Samreen
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
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21
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Hanna D, Makar M, Berger A, Johal AS, Confer BD, Khara HS. Immediate-use strategy is as safe and effective as delayed-use strategy following percutaneous endoscopic gastrostomy tube placement: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:120-127. [PMID: 37904600 DOI: 10.1002/jpen.2575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tube placement is the most common enteral access for long-term feeding. The aim of our study is to assess the feasibility and safety of immediate PEG tube use after initial placement. METHODS We conducted a single-center retrospective cohort study between August 2006 and August 2016. Prior to August 2011, tube feedings were delayed for ≥4 h after initial PEG placement, compared with immediate use (<1 h) after August 2011. Primary outcomes were complication rates within 30 days of placement. Secondary outcomes were impact of morbidity, mortality, length of stay, and need for repeat PEG placement. RESULTS Our study included 1296 patients during the 10-year period, of which 704 underwent delayed use and 592 underwent immediate use (744 inpatient and 552 outpatient). There were no significant differences between the delayed-use and immediate-use PEG with regard to complications (3.4% vs 4.4%; P = 0.76). Subgroup analysis also reflected no significant differences in complications between inpatient and outpatient groups. For inpatients, there were no substantial differences in inpatient mortality (3.9% vs 3.3%; P = 0.70), mortality within 30 days of discharge (13.8% vs 13.1%; P = 0.15), readmissions (38.2% vs 34.3%; P = 0.23), repeat PEG placement (0.7% vs 1.5%; P = 0.46), and length of stay (13.3 vs 13.9 days; P = 0.99). CONCLUSION Patients who received immediate enteral nutrition after PEG tube placement did not have any increased complications, morbidity, or mortality; and it is just as safe when compared with patients who received delayed feeding.
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Affiliation(s)
- David Hanna
- Department of Gastroenterology, Hepatology, and Clinical Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Michael Makar
- Department of Gastroenterology, Hepatology, and Clinical Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Andrea Berger
- Department of Population Health Sciences, Biostatistics Core, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Amitpal S Johal
- Department of Gastroenterology, Hepatology, and Clinical Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Bradley D Confer
- Department of Gastroenterology, Hepatology, and Clinical Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Harshit S Khara
- Department of Gastroenterology, Hepatology, and Clinical Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
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22
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Smith T, Blum R, Rozdolski R. Management of an Ingested Foreign Body in a COVID-Positive Patient. Anesth Prog 2023; 70:178-183. [PMID: 38221701 PMCID: PMC11088193 DOI: 10.2344/anpr-70-03-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/09/2023] [Indexed: 01/16/2024] Open
Abstract
This case report describes a 51-year-old man who swallowed an amalgam fragment dislodged during dental treatment performed without a throat screen. The patient was transferred to the emergency department, where the foreign body was confirmed to be in the esophagus following radiographic imaging. Foreign body removal from the esophagus is routinely achieved via esophagogastroduodenoscopy (EGD). However, this incident occurred in September 2020, at the height of the COVID-19 pandemic. Because of the patient's preoperative positive COVID-19 test, the option for EGD retrieval was eliminated per hospital protocol. Instead, a noninvasive approach with serial radiographic monitoring was deemed mandatory to observe the fragment as it passed through the gastrointestinal tract, warranted by the small size of the foreign body and the patient's lack of signs and symptoms of respiratory distress. This case report reinforces the importance of using airway protection during every dental procedure. Furthermore, reevaluation of EGD as the gold standard for treatment of ingested small materials may be warranted.
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Affiliation(s)
- Tiffany Smith
- Touro College of Dental Medicine, Hawthorne, New York
| | - Rachel Blum
- Touro College of Dental Medicine, Hawthorne, New York
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23
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McSorley B, Chugh A, Abazi T, Lerner D, Jobe S, Pan AY, Zhang L, Sharma R, Ashai-Khan F. Implementation of a Bleeding Risk Screening Tool and Hematology Referral Process Prior to Pediatric Endoscopy. J Pediatr Gastroenterol Nutr 2023; 77:661-665. [PMID: 37608441 DOI: 10.1097/mpg.0000000000003929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) endoscopic procedures are considered low risk with an overall bleeding risk for upper and lower endoscopies of 0.11%. However, a certain population of patients may have a higher risk for bleeding, and there is not a standardized process for screening patients to determine who these patients are. METHODS At Children's Wisconsin, our gastroenterology and hematology divisions adapted an abbreviated version of a validated, history-based bleeding risk screening tool and implemented a hematology referral process to identify those at risk for bleeding prior to their first endoscopy. Provider compliance with the bleeding screen, referral to hematology, time to be seen in hematology clinic, new diagnoses of bleeding disorders, and bleeding complications were assessed from 2019 to 2021 across 3 phases. RESULTS Provider compliance with the bleeding screen improved throughout our study from 48% (120/251) to 75% (189/253). For those who screened positive, compliance with referral to hematology ranged from 38% to 74% across our phases. The overall time to be seen by hematology decreased from 30 days to 7.5 days. Eighteen patients ultimately screened positive and were seen in hematology clinic, of whom 22% (4/18) were diagnosed with a new bleeding disorder. No bleeding complications were seen in our study population. CONCLUSIONS Our quality improvement project provided a standardized screening tool to assess preoperative bleeding risk and reinforced the value of a history-based screening tool. This modified screening tool identified those with an undiagnosed bleeding disorder and preventative measures were undertaken to prevent procedural bleeding complications.
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Affiliation(s)
- Brianna McSorley
- From the Division of Pediatric Gastroenterology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | - Ankur Chugh
- From the Division of Pediatric Gastroenterology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | - Tea Abazi
- From the Division of Pediatric Gastroenterology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | - Diana Lerner
- From the Division of Pediatric Gastroenterology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | - Shawn Jobe
- the Center for Bleeding and Clotting Disorders, Michigan State University College of Human Medicine, East Lansing, MI
| | - Amy Y Pan
- the Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Liyun Zhang
- the Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Ruchika Sharma
- the Division of Pediatric Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Farhat Ashai-Khan
- From the Division of Pediatric Gastroenterology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
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24
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Profit DD. Describing and Predicting Preprocedural Anxiety in Patients Scheduled for Advanced Gastrointestinal Endoscopy During the COVID-19 Pandemic. Gastroenterol Nurs 2023; 46:475-488. [PMID: 37639614 DOI: 10.1097/sga.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/26/2023] [Indexed: 08/31/2023] Open
Abstract
Advanced gastrointestinal endoscopy includes a group of specialized procedures and interventions that are being performed more frequently, with little attention given to a patient's preprocedural anxiety issues. Compounding this concern, in 2020 the COVID-19 pandemic resulted in the delay of many endoscopy cases. It is unknown how this affected the anxiety of patients preparing for advanced endoscopy procedures. Patients with higher anxiety require higher doses of anesthetic medications, and experience increased pain and decreased satisfaction. The purpose of this study was to describe the biological, psychological, and social attributes of patients and identify whether social support, COVID-19-related anxiety, delay of procedure, patient's physical status, and procedural indication category were predictors of state anxiety levels in patients undergoing advanced gastrointestinal endoscopy during the COVID-19 pandemic. The research study was a cross-sectional descriptive design with 90 patients. Patients were classified into low state and high state anxiety groups. Fifty-eight percent of patients had high state anxiety scores. Using logistic regression, social support was identified as a predictor of preprocedural anxiety (odds ratio [OR] = 0.318 [95% confidence interval, CI = 0.170, 0.597, p < .001]) as less social support was associated with higher anxiety. It is imperative that strategies to maximize social support are reinforced.
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Affiliation(s)
- Dawn Donahue Profit
- Dawn Donahue Profit, PhD, RN, is Staff Development Specialist, Nursing Staff Development, UK HealthCare, Lexington, Kentucky
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25
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Singh AK, Reddy YR, Jena A, Appasani S, Gupta P, Sinha SK, Kochhar R. Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center. Surg Endosc 2023; 37:8236-8244. [PMID: 37653157 DOI: 10.1007/s00464-023-10384-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/06/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators. METHODS Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14 mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications. RESULTS Of the 189 patients (mean age 32.17 ± 12.12 years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success. CONCLUSION Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.
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Affiliation(s)
- Anupam Kumar Singh
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Yalaka Rami Reddy
- Department of Gastroenterology, STAR Hospital, Nanakramguda, Hyderabad, India
| | - Anuraag Jena
- Department of Gastroenterology, Topiwala National Medical College & BYL Nair Hospital, Mumbai, India
| | - Sreekanth Appasani
- Department of Medical Gastroenterology, KIMS Hospital, Secunderabad, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
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Zeng R, Pu X, Chen S, Chen C, Chen Y, Chen W, Fu H. Oropharynx pain, discomfort, and economic impact of transesophageal echocardiography for planned radio-frequency catheter ablation in patients with atrial fibrillation: A cross-sectional survey study. IJC HEART & VASCULATURE 2023; 48:101266. [PMID: 37719868 PMCID: PMC10500450 DOI: 10.1016/j.ijcha.2023.101266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/19/2023]
Abstract
Background To survey the unmet medical needs associated with atrium thrombus screening in Chinese patients with atrial fibrillation (AF) who underwent transesophageal echocardiography (TEE) for planned radio-frequency catheter ablation (RFCA). Methods This cross-sectional survey study interviewed 300 patients who underwent their first TEE for planned RFCA. The surveyed information included patients' anxiety, oropharynx pain and discomfort, time expense, and patient satisfaction related to TEE examination. Patient preference for a new atrium thrombus screening technology, hospital length of stay (LOS) of RFCA, and hospital costs of RFCA in these surveyed patients were collected as well. Descriptive statistical methods were used to summarize the collected survey information. Results Of the 300 interviewed patients, 36.3% reported anxiety before TEE examination, 58.6% reported oropharynx pain related to TEE, and 76.2% reported oropharynx discomforts, mainly including foreign body sensation (54.3%), dry heaves (33.8%), nausea (31.9%), and bleeding (22.9%). Even though 62.3% were satisfied with TEE, 84.3% preferred a new technology to replace TEE. Conducting outpatient TEE took more wait time (4.4 days vs. 0.1 days, p = 0.016) but led to significantly shorter hospital LOS (3.8 days vs. 6.4 days, p < 0.001) and significant lower hospital costs for RFCA (¥74,097 vs. ¥85,843, p < 0.001) than conducting inpatient TEE. Conclusions Most AF patients experienced oropharynx pain and discomfort during or after TEE. Although more than half of AF patients were satisfied with TEE, most AF patients preferred a new technology to replace TEE for atrium thrombus screening. TEE was associated with economic impact on RFCA irrespective of TEE conducting settings.
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Affiliation(s)
- Rui Zeng
- West China Hospital of Sichuan University, Chengdu, China
| | - Xiaobo Pu
- West China Hospital of Sichuan University, Chengdu, China
| | - Shi Chen
- West China Hospital of Sichuan University, Chengdu, China
| | - Chunjia Chen
- Changsha Normin Health Technology Ltd., Changsha, China
| | - Yi Chen
- Changsha Normin Health Technology Ltd., Changsha, China
| | - Wendong Chen
- Normin Health Consulting Ltd., Mississauga, Ontario, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Hua Fu
- West China Hospital of Sichuan University, Chengdu, China
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27
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Ledder O, Woynarowski M, Kamińska D, Łazowska-Przeorek I, Pieczarkowski S, Romano C, Lev-Tzion R, Holon M, Nita A, Rybak A, Jarocka-Cyrta E, Korczowski B, Czkwianianc E, Hojsak I, Szaflarska-Popławska A, Hauser B, Scheers I, Sharma S, Oliva S, Furlano R, Tzivinikos C, Liu QY, Giefer M, Mamula P, Grossman A, Kelsen J, Edelstein B, Antoine M, Thomson M, Homan M. Identification of Iatrogenic Perforation in Pediatric Gastrointestinal Endoscopy. J Pediatr Gastroenterol Nutr 2023; 77:401-406. [PMID: 37276149 DOI: 10.1097/mpg.0000000000003852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Iatrogenic viscus perforation in pediatric gastrointestinal endoscopy (GIE) is a very rare, yet potentially life-threatening event. There are no evidence-based recommendations relating to immediate post-procedure follow-up to identify perforations and allow for timely management. This study aims to characterize the presentation of children with post-GIE perforation to better rationalize post-procedure recommendations. METHODS Retrospective study based on unrestricted pooled data from centers throughout Europe, North America, and the Middle East affiliated with the Endoscopy Special Interest Groups of European Society for Paediatric Gastroenterology Hepatology and Nutrition and North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Procedural and patient data relating to clinical presentation of the perforation were recorded on standardized REDCap case-report forms. RESULTS Fifty-nine cases of viscus perforation were recorded [median age 6 years (interquartile range 3-13)]; 29 of 59 (49%) occurred following esophagogastroduodenoscopy, 26 of 59 (44%) following ileocolonoscopy, with 2 of 59 (3%) cases each following balloon enteroscopy and endoscopic retrograde cholangiopancreatography; 28 of 59 (48%) of perforations were identified during the procedure [26/28 (93%) endoscopically, 2/28 (7%) by fluoroscopy], and a further 5 of 59 (9%) identified within 4 hours. Overall 80% of perforations were identified within 12 hours. Among perforations identified subsequent to the procedure 19 of 31 (61%) presented with pain, 16 of 31 (52%) presented with fever, and 10 of 31 (32%) presented with abdominal rigidity or dyspnea; 30 of 59 (51%) were managed surgically, 17 of 59 (29%) managed conservatively, and 9 of 59 (15%) endoscopically; 4 of 59 (7%) patients died, all following esophageal perforation. CONCLUSIONS Iatrogenic perforation was identified immediately in over half of cases and in 80% of cases within 12 hours. This novel data can be utilized to generate guiding principles of post-procedural follow-up and monitoring. PLAIN LANGUAGE SUMMARY Bowel perforation following pediatric gastrointestinal endoscopy is very rare with no evidence to base post-procedure follow-up for high-risk procedures. We found that half were identified immediately with the large majority identified within 12 hours, mostly due to pain and fever.
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Affiliation(s)
- Oren Ledder
- From Juliet Keidan Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
- Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | | | | | - Claudio Romano
- the Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Raffi Lev-Tzion
- From Juliet Keidan Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Andreia Nita
- Great Ormond Street Hospital, London, United Kingdom
| | - Anna Rybak
- Great Ormond Street Hospital, London, United Kingdom
| | | | - Bartosz Korczowski
- the Department of Pediatrics and Pediatric Gastroenterology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rzeszów, Poland
| | | | - Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | | | | | - Isabelle Scheers
- the Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Shishu Sharma
- Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Salvatore Oliva
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy
| | | | | | - Quin Y Liu
- Cedars-Sinai Medical Center, Los Angles, CA
| | | | - Petar Mamula
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Judith Kelsen
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Matthieu Antoine
- Univ. Lille, CHU Lille, Gastroentérologie, Hépatologie et Nutrition Pédiatrique, Hôpital Jeanne de Flandre, Lille, France
| | - Mike Thomson
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy
| | - Matjaž Homan
- University Children's Hospital, Medical Faculty, Ljubljana, Slovenia
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Tan CQL, Loh GYW, Benjamin TWR, Koh CJ, Mok JSR, Hartono JL, Chua KTC, Tan HH, Siah KTH. Dental trauma in endoscopy: A systematic review and experience of a tertiary endoscopy centre. World J Gastrointest Endosc 2023; 15:518-527. [PMID: 37663114 PMCID: PMC10473904 DOI: 10.4253/wjge.v15.i8.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/22/2023] [Accepted: 07/06/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Dental injury is the leading cause of litigation in anaesthesia but an underrecognized preventable complication of endoscopy. AIM To determine frequency and effects of dental injury in endoscopy, we present findings from an audit of outpatient endoscopy procedures conducted at a tertiary university hospital and a systematic review of literature. METHODS Retrospective review of 11265 outpatient upper endoscopy procedures over the period of 1 June 2019 to 31 May 2021 identified dental related complications in 0.284% of procedures. Review of literature identified a similar rate of 0.33%. RESULTS Pre-existing dental pathology or the presence of prostheses makes damage more likely but sound teeth may be affected. Pre-endoscopic history and tooth examination are key for risk stratification and may be conducted succinctly with limited time outlay. Tooth retrieval should be prioritized in the event of dental injury to minimize aspiration and be followed by prompt dental consultation for specific management. CONCLUSION Dental complications occur in approximately 1 in 300 of upper endoscopy cases. These are easily preventable by pre-endoscopy screening. Protocols to mitigate dental injury are also suggested.
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Affiliation(s)
- Chelsea Qiu Lin Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117594, Singapore
| | - Gabrielle Yi Wen Loh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117594, Singapore
| | - Tay Wei Rong Benjamin
- Division of Gastroenterology and Hepatology, National University Health System, Singapore 119074, Singapore
| | - Calvin Jianyi Koh
- Division of Gastroenterology and Hepatology, National University Health System, Singapore 119074, Singapore
| | - John Shao Rong Mok
- Division of Gastroenterology and Hepatology, National University Health System, Singapore 119074, Singapore
| | - Juanda Leo Hartono
- Division of Gastroenterology and Hepatology, National University Health System, Singapore 119074, Singapore
| | | | - Hee Hon Tan
- Division of Prosthodontics, National University Centre for Oral Health, Singapore 119074, Singapore
| | - Kewin Tien Ho Siah
- Division of Gastroenterology and Hepatology, National University Health System, Singapore 119074, Singapore
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Du YC, Jiang D, Wu J. Predicting the Severity of Esophageal Varices in Patients with Hepatic Cirrhosis Using Non-Invasive Markers. Risk Manag Healthc Policy 2023; 16:1555-1566. [PMID: 37602362 PMCID: PMC10439804 DOI: 10.2147/rmhp.s418892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023] Open
Abstract
Background The presence and extent of severity of esophageal varices (EV) in patients with liver cirrhosis (LC) are predicted using noninvasive clinical, biochemical, and imaging parameters. The aim of this study was to investigate the accuracy of noninvasive predictors of EV, such as the platelet count-to-spleen diameter ratio (PSR), platelet count-to-spleen volume ratio (PSVR), spleen size (SZ), and a combination of these markers in determining the severity of EV in patients with cirrhosis. Methods We recruited 82 inpatients with LC from the Department of Gastroenterology at the First Affiliated Hospital of Guangxi Medical University between January 2018 and December 2019 for this diagnostic investigation. All patients underwent endoscopy, ultrasound, computed tomography, and routine laboratory investigations. For the study, we evaluated and compared the diagnostic accuracy of PSR, PSVR, SZ, and their combinations. Results There were significant differences in the area under the receiver operating characteristic (ROC) curve (AUC) in the prediction of severe and moderate/severe EV for all the variables. PSR+PSVR had the highest AUC at 0.735 (95% CI: 0.626-0.826) and 0.765 (95% CI: 0.659-0.852) for predicting severe and moderate/severe EV, respectively. There were statistically significant differences in the AUCs (95% CI) for PSR, PSVR, and PSR+PSVR in predicting the existence of EV. As per the overall model quality chart, the combination of PSR+PSVR was the best indicator for detecting the presence of EV (AUC, 0.696; 95% CI: 0.584-0.792). Conclusion In our study, we found that these noninvasive parameters could predict the extent of severity of EV in patients with LC. We anticipate the use of a combination of PSR + PSVR to emerge as the superior indicator as studies progress.
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Affiliation(s)
- Yang-Chun Du
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
- Department of Ultrasound, The People’s Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, Nanning, 530021, People’s Republic of China
| | - Dan Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Ji Wu
- Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
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Sohail R, Hassan IH, Rukh M, Saqib M, Iftikhar M, Mumtaz H. Assessing Thrombocytopenia and Chronic Liver Disease in Southeast Asia: A Multicentric Cross-Sectional Study. Cureus 2023; 15:e43356. [PMID: 37700968 PMCID: PMC10493634 DOI: 10.7759/cureus.43356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/14/2023] Open
Abstract
Background This multicentric cross-sectional study aimed to examine the prevalence of thrombocytopenia (TCP) and investigate the various causes of chronic liver disease (CLD) across 15 Southeast Asian (India, Pakistan, and Bangladesh) tertiary care centers over a three-month period. The study focused on assessing the fibrosis index (FI) and Model for End-Stage Liver Disease (MELD)-sodium (Na) score's capacity to grade and predict the progression and outcomes of patients with already diagnosed CLD. Methods The cross-sectional study enrolled 377 CLD patients. The study utilized admission registries from 15 tertiary care hospitals in Southeast Asia, spanning from April 2023 to June 2023. Various descriptive variables were collected, including gender, tobacco use (specifically, chewed tobacco), underlying etiology, presence of anemia, leukopenia, pancytopenia, infectious state, and liver cirrhosis diagnosed via traditional ultrasonography. This study examined liver failure indicators, including alanine transaminase levels, compensation status, TCP, and liver transplant (LT) listing. The MELD-Na score was the focus of frequency and percentage analysis. MELD-Na and FI medians and standard deviations were provided. Results The study of 377 patients with CLD found that TCP was present in 4% of patients and leukopenia was present in 12% of patients. The risk of TCP was significantly higher in leukopenic patients (89.5%) than in non-leukopenic patients (52.5%) (p = 0.003). The most common CLD cause was undiagnosable (31%), followed by autoimmune (26%), hepatitis C virus (21%), hepatitis B virus (14%), and schistosomiasis (8%). The majority of patients (98%) had decompensated liver disease. Of the patients, 64% had TCP, while 36% did not. The illness severity indicators MELD score and FI had mean ± SD values of 16.89 ± 6.42 and 4.1 ± 1.06, respectively. Similarly, the prevalence of LT needs among traditional ultrasonography-diagnosed cirrhotic patients was 83.1%, compared to 59.6% among non-cirrhotic patients (p = 0.001). Conclusion Leukopenia and TCP may be linked, which may affect CLD treatment and prognosis in this population. Non-invasive indicators like the FI and MELD-Na score can detect liver fibrosis and severity without invasive procedures, enhancing patient management. These findings highlight the need to improve early diagnosis methods for CLD in Southeast Asia and raise awareness among clinicians about effective diagnostic strategies for non-infectious causes of CLD.
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Affiliation(s)
- Ramsha Sohail
- Department of Medicine, Jackson Park Hospital, Chicago, USA
| | - Imran H Hassan
- Department of Medicine, Grantham and District Hospital, Grantham, GBR
| | - Mah Rukh
- Department of Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | - Muhammad Saqib
- Department of Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | | | - Hassan Mumtaz
- Department of Urology, Guy's and St. Thomas' Hospital, London, GBR
- General Practice, Surrey Docks Health Centre, London, GBR
- Department of Public Health, Health Services Academy, Islamabad, PAK
- Department of Clinical Research, Maroof International Hospital, Islamabad, PAK
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Wechsler EV, Ahuja NK, Brenner D, Chan W, Chang L, Chey WD, Lembo AJ, Moshiree B, Nee J, Shah SC, Staller K, Shah ED. Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia. Clin Gastroenterol Hepatol 2023; 21:2378-2388.e28. [PMID: 36646234 PMCID: PMC10542651 DOI: 10.1016/j.cgh.2023.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/01/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. METHODS We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. RESULTS From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. CONCLUSIONS Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.
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Affiliation(s)
- Emily V Wechsler
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania
| | - Darren Brenner
- Division of Gastroenterology, Northwestern Medicine, Chicago, Illinois
| | - Walter Chan
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lin Chang
- Division of Gastroenterology, University of California Los Angeles, Los Angeles, California
| | - William D Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - Anthony J Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Baha Moshiree
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shailja C Shah
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric D Shah
- Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, Dartmouth Health, Lebanon, New Hampshire; Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan.
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Vu Trung K, Abou-Ali E, Caillol F, Paik WH, Napoleon B, Masaryk V, van der Wiel SE, Pérez-Cuadrado-Robles E, Musquer N, Halimi A, Soares K, Souche FR, Seyfried S, Petrone MC, Crippa S, Kleemann T, Albers D, Weismüller TJ, Dugic A, Meier B, Wedi E, Schiemer M, Regner S, Gaujoux S, Hollenbach M. Endoscopic papillectomy for ampullary lesions in patients with familial adenomatous polyposis compared with sporadic lesions: a propensity score-matched cohort. Endoscopy 2023; 55:709-718. [PMID: 36746390 DOI: 10.1055/a-2029-2935] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Familial adenomatous polyposis (FAP) is a rare inherited syndrome that predisposes the patient to cancer. Treatment of FAP-related ampullary lesions is challenging and the role of endoscopic papillectomy has not been elucidated. We retrospectively analyzed the outcomes of endoscopic papillectomy in matched cohorts of FAP-related and sporadic ampullary lesions (SALs). METHODS This retrospective multicenter study included 1422 endoscopic papillectomy procedures. Propensity score matching including age, sex, comorbidity, histologic subtype, and size was performed. Main outcomes were complete resection (R0), technical success, complications, and recurrence. RESULTS Propensity score matching identified 202 patients (101 FAP, 101 SAL) with comparable baseline characteristics. FAP patients were mainly asymptomatic (79.2 % [95 %CI 71.2-87.3] vs. 46.5 % [95 %CI 36.6-56.4]); P < 0.001). The initial R0 rate was significantly lower in FAP patients (63.4 % [95 %CI 53.8-72.9] vs. 83.2 % [95 %CI 75.8-90.6]; P = 0.001). After repeated interventions (mean 1.30 per patient), R0 was comparable (FAP 93.1 % [95 %CI 88.0-98.1] vs. SAL 97.0 % [95 %CI 93.7-100]; P = 0.19). Adverse events occurred in 28.7 %. Pancreatitis and bleeding were the most common adverse events in both groups. Severe adverse events were rare (3.5 %). Overall, 21 FAP patients (20.8 % [95 %CI 12.7-28.8]) and 16 SAL patients (15.8 % [95 %CI 8.6-23.1]; P = 0.36) had recurrence. Recurrences occurred later in FAP patients (25 [95 %CI 18.3-31.7] vs. 2 [95 %CI CI 0.06-3.9] months). CONCLUSIONS Endoscopic papillectomy was safe and effective in FAP-related ampullary lesions. Criteria for endoscopic resection of ampullary lesions can be extended to FAP patients. FAP patients have a lifetime risk of relapse even after complete resection, and require long-time surveillance.
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Affiliation(s)
- Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Einas Abou-Ali
- Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Paris Descartes University, Paris, France
| | - Fabrice Caillol
- Department of Endoscopy, Institut Paoli Calmettes, Marseille, France
| | - Woo H Paik
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Viliam Masaryk
- Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany
| | - Sophia E van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enrique Pérez-Cuadrado-Robles
- Interventional Endoscopy, Hôpital Européen Georges-Pompidou, Department of Gastroenterology, Georges-Pompidou European Hospital, Paris, France
- Department of Gastroenterology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | | | - Asif Halimi
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, University of Umeå, Umeå, Sweden
| | - Kevin Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Francois R Souche
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Steffen Seyfried
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
- Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Maria C Petrone
- Endosonography Unit, Pancreato-Biliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Vita Salute San Raffaele University, Milan, Italy
| | - Tobias Kleemann
- Department of Gastroenterology and Rheumatology, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - David Albers
- Department of Medicine and Gastroenterology, Contilia Clinic Essen, Essen, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine - Gastroenterology and Oncology, Vivantes Humboldt Hospital, Berlin, Germany
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Ana Dugic
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Benjamin Meier
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes and Infectious Diseases; RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medicine Göttingen, Göttingen, Germany
- Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Moritz Schiemer
- Department of Medicine II, University of Freiburg Medical Center, Freiburg, Germany
| | - Sara Regner
- Department of Clinical Sciences Malmö, Section for Surgery, Lund University, Lund, Sweden
| | - Sebastien Gaujoux
- Department of Digestive and HBP Surgery, Groupe Hospitalier Pitié-Salpêtrière APHP, Médecine Sorbonne Université, Paris, France
| | - Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
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Ismail M. Prediction of High-Risk Varices in Patients with Compensated Advanced Chronic Liver Disease in Saudi Arabia. Clin Exp Gastroenterol 2023; 16:117-127. [PMID: 37489180 PMCID: PMC10363351 DOI: 10.2147/ceg.s410041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Abstract
Purpose Liver stiffness and low platelet count can predict portal hypertension and high-risk varices (HRVs) in patients with cirrhosis. Thus, screening endoscopy may not be required for all patients with compensated advanced chronic liver disease (cACLD). However, data from Saudi Arabia are limited. This study aimed to validate the Baveno VI and expanded Baveno VI criteria for screening endoscopy and identify the risk factors associated with HRVs in patients with cACLD in Saudi Arabia. Patients and Methods We analyzed data from 215 patients with cACLD diagnosed on transient elastography (LSM > 10 kPa) and had paired platelet count and screening upper endoscopy performed within one year of diagnosis. HRVs or varices needing treatment (VNTs) were defined as medium-to-large esophageal varices (EVs), small EVs with red flags, or gastric varices. Sensitivity, specificity, and area under the receiver operating characteristic curve were calculated. Univariate and multivariate logistic regression analyses identified HRV risk factors. Results The Baveno VI criteria spared 50.7% of endoscopies, missing 3.7% of VNTs, while the expanded Baveno VI criteria spared 63.7% of endoscopies, missing 5.1% VNTs. An LSM <20 kPa and platelet count > 150,000/µL were associated with HRV in 8.1% and 8.3%, respectively. While an LSM <25 kPa and platelet count > 110,000/µL were associated with HRV in 9.7% and 9%, respectively. The Baveno VI criteria had sensitivity and specificity of 76% and 55%, while the expanded criteria had 67% and 69%, respectively. Baveno VI criteria performed better in hepatitis C virus patients than nonalcoholic fatty liver disease patients. Multivariate logistic regression analysis revealed platelet count and LSM as predictors of HRV. Conclusion The Baveno VI criteria effectively identified HRVs in cACLD patients from Saudi Arabia, reducing unnecessary endoscopies. Although the expanded criteria avoided more endoscopies, it led to a higher rate of missed HRVs.
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Affiliation(s)
- Mona Ismail
- Division of Gastroenterology, Department of Internal Medicine, King Fahd Hospital of the University, Alkhobar, Saudi Arabia
- College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
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Liu CT, Wu FC, Zhuang YX, Huang XY, Li XH, Qu QQ, Peng YH, Xu YW, Chen SL, Huang XC. The diagnostic value of serum insulin-like growth factor binding protein 7 in gastric cancer. PeerJ 2023; 11:e15419. [PMID: 37304887 PMCID: PMC10249617 DOI: 10.7717/peerj.15419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Backgrounds Early detection might help in reducing the burden and promoting the survival rate of gastric cancers. Herein, we tried to explore the diagnostic value of insulin-like growth factor binding protein 7 (IGFBP7) in gastric cancers. Methods In this study, we first analyzed the expression levels and prognostic value of IGFBP7 mRNA in gastric cancers from The Cancer Genome Atlas (TCGA) database. Then, we recruited 169 gastric cancer patients and 100 normal controls as training cohort, and 55 gastric cancer patients and 55 normal controls as independent validation cohort. Enzyme-linked immunosorbent assay was applied to test the serum levels of IGFBP7. The receiver operating characteristic curve (ROC) and the area under the curve (AUC) were applied to evaluation the diagnostic value. Results TCGA showed that IGFBP7 mRNA was dysregulated and associated with prognosis in gastric cancer patients. Then, we examined the expression of serum IGFBP7 and found that serum IGFBP7 expressed lower in gastric cancer patients than normal controls both in training and independent validation cohorts (p < 0.0001). In training cohort, with the cutoff value of 1.515 ng/ml, the AUC for distinguishing gastric cancer patients was 0.774 (95% CI [0.713-0.836]) with sensitivity of 36.7% (95% CI [29.5-44.5]) and specificity of 90.0% (95% CI [82.0-94.8]). As for early-stage EJA, the AUC was 0.773 (95% CI [0.701-0.845]) with the sensitivity of 33.3% (95% CI [14.4-58.8]). In independent validation cohort, with the same cutoff value, the AUC reached to 0.758 (95% CI [0.664-0.852]). Similarly, for early-stage gastric cancer diagnosis in the independent validation cohort, the AUC value was 0.778 (95% CI [0.673-0.882]). Conclusions This study indicated that serum IGFBP7 might act as a potential early diagnostic marker for gastric cancers.
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Affiliation(s)
- Can-Tong Liu
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Esophageal Cancer Prevention and Control Research Center, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, China
| | - Fang-Cai Wu
- Esophageal Cancer Prevention and Control Research Center, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Department of Radiation Oncology, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Yi-Xuan Zhuang
- Department of Pathology, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xin-Yi Huang
- Department of Gastrointestinal Endoscopy, the First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xin-Hao Li
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Qi-Qi Qu
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Yu-Hui Peng
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Esophageal Cancer Prevention and Control Research Center, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, China
| | - Yi-Wei Xu
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Esophageal Cancer Prevention and Control Research Center, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, China
| | - Shu-Lin Chen
- Department of Clinical Laboratory Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xu-Chun Huang
- Department of Clinical Laboratory Medicine, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Esophageal Cancer Prevention and Control Research Center, the Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, China
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Crispino F, Merola E, Tasini E, Cammà C, di Marco V, de Pretis G, Michielan A. Adverse events in gastrointestinal endoscopy: Validation of the AGREE classification in a real-life 5-year setting. Dig Liver Dis 2023:S1590-8658(23)00566-2. [PMID: 37100710 DOI: 10.1016/j.dld.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/08/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The novel AGREE classification for adverse events (AEs) in gastrointestinal (GI) endoscopy has not yet been validated in a real-world setting. AIMS Our study aims to evaluate the correlation between the grades of AEs in the ASGE and AGREE classifications and to assess the interobserver agreement of the two classification systems. METHODS The correlation and association between the AE grades of the ASGE and AGREE classifications were analyzed using the Spearman rank correlation test and the chi-squared analysis, respectively. A weighted Cohen's kappa coefficient analysis was performed to determine the interobserver agreement of both classification systems. RESULTS We prospectively collected the AEs that occurred in our endoscopy unit over the past five years. A total of 226 AEs (226/84,863, 0.3%) occurred. There was a correlation between the ASGE and AGREE classifications (ρ = 0.61) and a moderately significant association (p < 0.01, Cramer's V = 0.7). The interobserver agreement for the ASGE classification was fair (kappa 0.60, 95% confidence interval [CI]: 0.54, 0.67), whereas it was good for the AGREE classification (kappa 0.80, 95% CI: 0.62, 0.87). CONCLUSIONS The AGREE classification was validated for the first time in a real-world setting and showed a positive correlation and higher interobserver agreement than the ASGE classification.
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Affiliation(s)
- Federica Crispino
- Dipartimento di Promozione Della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza (PROMISE), Gastroenterology and Hepatology Unit, Piazza delle Cliniche 2, Palermo 90127, Italy; Azienda Provinciale per i Servizi Sanitari (APSS), Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Largo Medaglie D'Oro 9, Trento 38122, Italy
| | - Elettra Merola
- Azienda Provinciale per i Servizi Sanitari (APSS), Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Largo Medaglie D'Oro 9, Trento 38122, Italy; Gastroenterology Unit, G.B. Grassi Hospital (ASL Roma 3), Via Gian Carlo Passeroni 28, 00122 Lido di Ostia, Roma, Italy
| | - Enrico Tasini
- Azienda Provinciale per i Servizi Sanitari (APSS), Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Largo Medaglie D'Oro 9, Trento 38122, Italy
| | - Calogero Cammà
- Dipartimento di Promozione Della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza (PROMISE), Gastroenterology and Hepatology Unit, Piazza delle Cliniche 2, Palermo 90127, Italy
| | - Vito di Marco
- Dipartimento di Promozione Della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza (PROMISE), Gastroenterology and Hepatology Unit, Piazza delle Cliniche 2, Palermo 90127, Italy
| | - Giovanni de Pretis
- Azienda Provinciale per i Servizi Sanitari (APSS), Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Largo Medaglie D'Oro 9, Trento 38122, Italy
| | - Andrea Michielan
- Azienda Provinciale per i Servizi Sanitari (APSS), Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Largo Medaglie D'Oro 9, Trento 38122, Italy.
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Gan J, Chan YK, Segaran DC, Kovalik JP, Eng A, Lee PC, Tan J, Lim CH. Pepsin in saliva for the diagnosis of erosive esophagitis post-sleeve gastrectomy: a prospective observational study. Surg Endosc 2023:10.1007/s00464-023-10050-9. [PMID: 37055666 DOI: 10.1007/s00464-023-10050-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/26/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, new onset erosive esophagitis (EE) is a major shortcoming. Current recommendation is esophago-gastro-duodenoscopy (EGD) should be performed routinely at 1 year and subsequently every 2-3 years to enable the early detection of Barrett's or esophageal adenocarcinoma. This would put significant strains on resources and costs of bariatric program. Our study assesses the association between and diagnostic value of salivary pepsin concentration and endoscopically proven EE in post-LSG patients as a surrogate for EGD. METHODS Twenty patients on routine post-LSG endoscopy between June and September 2022 were recruited for this correlational pilot study. Under supervision, fasting and post-prandial saliva sample was collected and analyzed by Peptest lateral flow device. EGD examinations were performed, and patients completed a validated 25-item QoLRAD questionnaire. RESULTS We found a significant correlation between positive endoscopy findings of EE and salivary pepsin concentrations. The normal group had a lower mean fasting pepsin level (13.13 ng/mL ± 18.97) versus the EE-group (90.55 ng/mL ± 81.28, p = 0.009) and lower mean post-prandial pepsin level (30.50 ng/mL ± 57.72) versus the EE-group (135.09 ng/mL ± 130.17, p = 0.02). The predictive probabilities from the binary regression of fasting and post-prandial pepsin concentrations yield AUC of 0.955 ± 0.044 (95% CI 0.868 to 1.000, p < 0.001). CONCLUSION Our study distinctively identified salivary pepsin to have excellent sensitivity and negative predictive value in EE, potentially useful to preclude the need for post-LSG EGD in asymptomatic patients with low salivary pepsin.
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Affiliation(s)
- Jinyuan Gan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Yarn Kit Chan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Deepa Chandra Segaran
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jean-Paul Kovalik
- Division of Medicine, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Alvin Eng
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Phong Ching Lee
- Division of Medicine, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Tan
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chin Hong Lim
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore.
- Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
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Apte M, Calderwood AH. Practice Management: Fulfilling Trainee Education While Maintaining a High-Quality Endoscopy Unit. Clin Gastroenterol Hepatol 2023; 21:873-877.e1. [PMID: 36581223 DOI: 10.1016/j.cgh.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Manisha Apte
- Section of Gastroenterology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Audrey H Calderwood
- Section of Gastroenterology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Dartmouth Geisel School of Medicine and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
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The Association Between Low Body-Mass Index and Serious Post-endoscopic Adverse Events. Dig Dis Sci 2023; 68:2180-2187. [PMID: 36884185 DOI: 10.1007/s10620-023-07882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Low body mass index (LBMI) was associated with longer colonoscopy procedure time and procedural failure, and commonly considered to be a risk factor for post-endoscopic adverse events, but evidence is lacking. AIM We aimed to assess the association between serious adverse events (SAE) and LBMI. METHODS A single center retrospective cohort of patients with LBMI (BMI ≤ 18.5) undergoing an endoscopic procedure was matched (1:2 ratio) to a comparator group (19 ≤ BMI ≤ 30). Matching was performed according to age, gender, inflammatory bowel disease or malignancy diagnoses, previous abdomino-pelvic surgery, anticoagulation therapy and type of endoscopic procedure. The primary outcome was SAE, defined as bleeding, perforation, aspiration or infection, following the procedure. The attribution between each SAE and the endoscopic procedure was determined. Secondary outcomes included each complication alone and endoscopy-attributed SAEs. Univariate and multivariate analyses were applied. RESULTS 1986 patients were included (662 in the LBMI group). Baseline characteristics were mostly similar between the groups. The primary outcome occurred in 31/662 (4.7%) patients in the LBMI group and in 41/1324 (3.1%) patients in the comparator group (p = 0.098). Among the secondary outcomes, infections (2.1% vs. 0.8%, p = 0.016) occurred more frequently in the LBMI group. Multivariate analysis revealed an association between SAE and LBMI (OR 1.76, 95% CI 1.07-2.87), male gender, diagnosis of malignancy, high-risk endoscopic procedure, age > 40 years, and ambulatory setting. CONCLUSION Low BMI was associated with higher post-endoscopic serious adverse events. Special attention is required when performing endoscopy in this fragile patient population.
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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Chaikajornwat J, Pittayanon R, Ananchuensook P, Kongwibulwut M, Rerknimitr R. The comparison of aerosol exposures to endoscopy personnel performing diagnostic upper gastrointestinal endoscopy in patients with and without head box: A randomized control trial. J Gastroenterol Hepatol 2023; 38:233-240. [PMID: 36464891 DOI: 10.1111/jgh.16082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/11/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Esophagogastroduodenoscopy (EGD) has been identified as an aerosol-generating procedure (AGP) during the COVID-19 pandemic. The risk of AGP and benefits of utilizing protective measures have never been fully studied. METHODS A randomized control, open-label study in patients scheduled for diagnostic EGD between September and December 2021 was conducted. Patients were randomly assigned to either head box group or without head box group (control group). Particles were measured with six-size particle counters at the nurse anesthetist and endoscopist position. Primary composite outcomes were the mean difference of aerosol particle levels during and before EGD at the nurse anesthetist face position and at the endoscopist face position. Secondary outcomes were factors increasing aerosol particle levels and safety of the head box. RESULTS From 196 enrolled patients, 190 were analyzed. Baseline characteristics were not different between the two groups. The mean distance between endoscopist face and patient mouth was 67.2 ± 4.9 cm. The mean differences of 0.3-, 0.5-, and 1.0-μm particles during the procedure and at baseline before the procedure at nurse anesthetist position and the mean differences of 0.3-μm particles at the endoscopist position was found to have decreased in the head box group and increased in the control group (P < 0.001, 0.001, 0.014, and P < 0.001, respectively). Cough, burping, and body movement increased aerosol particles. No additional adverse events were observed in the head box group. CONCLUSIONS EGD with the head box is safe and can reduce significant aerosolization to endoscopy personnel including nurse anesthetists and endoscopists.
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Affiliation(s)
- Jukkaphop Chaikajornwat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Prooksa Ananchuensook
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Manasnun Kongwibulwut
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
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Al-Dholae MHH, Salah MK, Al-Ashmali OY, Al Mokdad ASM, Al-Madwami MA. Thrombocytopenia (TCP), MELD Score, and Fibrosis Index (FI) Among Hospitalized Patients with Chronic Liver Disease (CLD) in Ma'abar City, Dhamar Governorate, Yemen: A Cross-Sectional Study. Hepat Med 2023; 15:43-50. [PMID: 37143507 PMCID: PMC10153436 DOI: 10.2147/hmer.s392011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/24/2023] [Indexed: 05/06/2023] Open
Abstract
Purpose This study sought to assess the prevalence of thrombocytopenia (TCP), underlying aetiologies of chronic liver disease, and the grading and prognostic systems for chronic liver disease (CLD) using non-invasive biomarkers: the Fibrosis index and the Model for End-Stage Liver Disease-Na (MELD-Na) Score, respectively. Patients and Methods This was a 15-month multi-centric cross-sectional study of 105 patients with chronic liver disease (CLD). The study was conducted using Sept 2019 to Nov 2020 admission records of CLD patients from Ma'abar City in Dhamar Governorate, Yemen. Results A total of 63 (60%) and 42 (40%) patients were identified as thrombocytopenic and non-thrombocytopenic, respectively. The means ± SD of the MELD score and FI were 19 ± 7.302 and 4.1 ± 1.06. TCP prevalence among leukopenic and non-leukopenic patients was 89.5% and 53.5%, respectively (P = 0.004). Likewise, the prevalence of traditional-ultrasonography-diagnosed cirrhotic patients needing liver transplantation (LT) was 82.3% versus 61.3% among corresponding non-cirrhotic patients (P = 0.000). Conclusion The prevalence of TCP among the participants of this study was similar to the global rate. However, the prevalence of decompensation was much higher among CLD patients than that found elsewhere, highlighting a need to improve methods for the early diagnosis of CLD in Yemen. This study also identified problems with the diagnostic work-up for non-infectious aetiologies of CLD. The findings suggest the need to improve clinician awareness about effective diagnostic strategies for these aetiologies.
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Affiliation(s)
| | - Mohammed Kassim Salah
- Department of Internal Medicine, Faculty of Medicine & Health Sciences, Thamar University, Dhamar, Yemen
| | - Omar Yahya Al-Ashmali
- Department of Pediatrics, Al-Wahda Teaching Hospital, Thamar University, Ma’abar City, Dhamar Governorate, Yemen
- Correspondence: Omar Yahya Al-Ashmali, Department of Paediatrics, Al-Wahda Teaching Hospital, Thamar University, Ma’abar City, Dhamar Governorate, Yemen, Tel +967777638063, Email
| | | | - Mohammed Ali Al-Madwami
- Department of Internal Medicine, Faculty of Medicine & Health Sciences, Thamar University, Dhamar, Yemen
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AbiMansour JP, Garimella V, Petersen BT, Law RJ, Storm AC, Martin JA, Levy MJ, Abu Dayyeh BK, Chandrasekhara V. Risk of post-sphincterotomy bleeding in patients with thrombocytopenia. Ther Adv Gastrointest Endosc 2023; 16:26317745231200971. [PMID: 37767287 PMCID: PMC10521278 DOI: 10.1177/26317745231200971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Background Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Objective The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES. Design Retrospective observational cohort study. Methods Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review. Results A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not. Conclusion In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.
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Affiliation(s)
- Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vishal Garimella
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Bret T. Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - John A. Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Waddingham W, Kamran U, Kumar B, Trudgill NJ, Tsiamoulos ZP, Banks M. Complications of diagnostic upper Gastrointestinal endoscopy: common and rare - recognition, assessment and management. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000688. [PMID: 36572454 PMCID: PMC9806027 DOI: 10.1136/bmjgast-2021-000688] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 11/26/2022] [Indexed: 12/27/2022] Open
Abstract
A clear understanding of the potential complications or adverse events (AEs) of diagnostic endoscopy is an essential component of being an endoscopist. Creating a culture of safety and prevention of AEs should be part of routine endoscopy practice. Appropriate patient selection for procedures, informed consent, periprocedure risk assessments and a team approach, all contribute to reducing AEs. Early recognition, prompt management and transparent communication with patients are essential for the holistic and optimal management of AEs. In this review, we discuss the complications of diagnostic upper gastrointestinal endoscopy, including their recognition, treatment and prevention.
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Affiliation(s)
- William Waddingham
- Gastro-intestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Umair Kamran
- Department of gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Bhaskar Kumar
- Department of Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Nigel J Trudgill
- Department of gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Matthew Banks
- Gastro-intestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
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A. Aulinger B, H. Saner F, Stark K, Mayerle J, M. Lange C. Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:851-860. [PMID: 36345703 PMCID: PMC9981979 DOI: 10.3238/arztebl.m2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/22/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The proper management of patients being treated with platelet aggregation inhibitors or anticoagulant drugs is a common clinical problem for both elective and emergency procedures in gastroenterology and visceral surgery. The essential matters that must be kept in mind in this situation are the hemorrhagic risk of the procedure, the indication for anticoagulation, and the pharmacology of anticoagulant drugs and platelet aggregation inhibitors. METHODS This review is based on publications retrieved by a selective search in PubMed and on the guidelines of the relevant specialist societies. RESULTS Nearly all procedures in gastroenterology and visceral surgery can be performed under monotherapy with acetyl - salicylic acid. Other platelet aggregation inhibitors, such as clopidogrel or prasugrel, or anticoagulant drugs generally do not need to paused before diagnostic endoscopic procedures with a low risk of bleeding (<1.5%), but they must be paused before procedures in gastroenterology and visceral surgery where the risk of bleeding is high (≥ 1.5%). Bridging with heparin is reserved for patients with a very high risk of thromboembolism ( ≥ 5%). CONCLUSION Knowledge of the current recommendations on the management of anticoagulants before gastroenterological and visceral surgical procedures gives the clinician a well-founded means of dealing with this complex and common clinical situation.
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Affiliation(s)
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany
| | - Konstantin Stark
- Medizinische Klinik und Poliklinik I, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Julia Mayerle
- Department of Internal Medicine II, LMU University Hospital Munich, Germany
| | - Christian M. Lange
- Department of Internal Medicine II, LMU University Hospital Munich, Germany,*Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Marchioninistrasse 15,D- 81337 Munich, Germany
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45
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Lew D, Abboud Y, Picha SM, Lai EC, Park KH, Pandol SJ, Almario CV, Lo SK, Gaddam S, Gaddam S. Quality improvement project on the development of a management algorithm for iatrogenic perforations and the long-term impact on physician knowledge. Endosc Int Open 2022; 10:E1481-E1490. [PMID: 36397866 PMCID: PMC9666066 DOI: 10.1055/a-1914-6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/24/2022] [Indexed: 10/16/2022] Open
Abstract
Background and study aims Acute iatrogenic endoscopic perforations (AIEPs) can have high morbidity and mortality, especially colonic perforations. Knowledge of diagnosis and AIEP management can improve patient care. The aims of this study were to: develop an evidence-based AIEP management algorithm; study its short-term and long-term impact on physician knowledge; and evaluate physician knowledge using hypothetical clinical scenarios. Methods An institutional AIEP management algorithm was created using the most current recommendations from the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy. Input from advanced endoscopists, nurses, and anesthesiologists was also obtained. We assessed change in physician knowledge using a 10-item questionnaire before (pretest), a standardized one-page AIEP educational material and algorithm immediately after (post-test) to test short-term retention, and 6 months later (6-month reassessment) to test long-term retention. With the 6-month reassessment, two clinical scenarios based on real AIEP were presented to evaluate application of knowledge. Results Twenty-eight subjects (8 gastroenterology fellows and 20 practicing gastroenterologists) participated in the assessments. Pretest and immediate post-test accuracies were 75 % and 95 % ( P < 0.01), respectively. Six-month reassessment accuracies were 83.6 %, significantly worse compared to post-test accuracies ( P < 0.05), but significantly improved compared to pretest accuracies ( P < 0.05). Accuracies for clinical scenarios #1 and #2 were 67.5 % and 60.3 %, respectively. Fellows had similar accuracies when compared to practicing gastroenterologists. Conclusions Using standardized methodology and a multidisciplinary approach, an AIEP management algorithm was created to improve patient care and alleviate physician and staff stress. In addition, we showed that a one-page educational document on perforations can significantly improve short-term and long-term physician knowledge, although periodic reeducation is needed.
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Affiliation(s)
- Daniel Lew
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Yazan Abboud
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Suellen M. Picha
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Ellis C. Lai
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Kenneth H. Park
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Stephen J. Pandol
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Christopher V. Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Simon K. Lo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Srinivas Gaddam
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Srinivas Gaddam
- Pancreaticobiliary, Cedars-Sinai Medical Center, Los Angeles, United States
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Sankar A, Ladha KS, Grover SC, Jogendran R, Tamming D, Razak F, Verma AA. Predictors of ICU admission associated with gastrointestinal endoscopy in medical inpatients: A retrospective cohort study. J Gastroenterol Hepatol 2022; 37:2074-2082. [PMID: 35869833 DOI: 10.1111/jgh.15969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Gastrointestinal (GI) endoscopic procedures are commonly performed in medical inpatients. Limited prior research has examined factors associated with intensive care unit (ICU) admission after GI endoscopy in medical inpatients. METHODS This retrospective cohort study was conducted using routinely-collected clinical and administrative data from all general medicine hospitalizations at five academic hospitals in Toronto, Canada between 2010 and 2020. We describe ICU admission and death within 48 h of GI endoscopy in medical inpatients. We examined adjusted associations of patient and procedural factors with ICU admission or death using multivariable logistic regression. RESULTS Among 18 290 medical inpatients who underwent endoscopy, 900 (4.9%) required ICU admission or died within 48 h of endoscopy. Following risk adjustment, ICU admission or death were associated with the following procedural factors: endoscopy on the day of hospital admission (aOR 3.16 [2.38-4.21]) or 1 day after admission (aOR 1.92 [1.51-2.44]) and esophagogastroduodenoscopy (EGD) procedures; and the following patient factors: Charlson comorbidity index of two (aOR 1.38 [1.05-1.81]) or three or greater (aOR 1.84 [1.47-2.29]), older age, male sex, lower hemoglobin prior to endoscopy, increased creatinine prior to endoscopy, an admitting diagnosis of liver disease and certain medications (antiplatelet agents and corticosteroids). CONCLUSIONS ICU admission or death after endoscopy was associated with procedural factors such as EGD and timing of endoscopy, and patient factors indicative of acute illness and greater comorbidity. These findings can contribute to improved triage and monitoring for patients requiring inpatient endoscopy.
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Affiliation(s)
- Ashwin Sankar
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Karim S Ladha
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Samir C Grover
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Division of Gastroenterology, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Rohit Jogendran
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Tamming
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Fahad Razak
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Amol A Verma
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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Muacevic A, Adler JR, Draganov P, Bursian A, White JD. Gas Pressure From the Endoscope: An Unexplored Contributor to Morbidity and Mortality? Cureus 2022; 14:e31779. [PMID: 36569698 PMCID: PMC9774048 DOI: 10.7759/cureus.31779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background It has been shown that the incidence of venous air embolism and venous carbon dioxide (CO2) embolism is high during endoscopic retrograde cholangiopancreatography (ERCP). We examined insufflating gas flow and maximum pressure produced by three types of commonly used endoscopes because we could not readily locate technical data for endoscope gas flow and maximum emitted pressure in the manufacturer's manuals. Methods We tested the Olympus GIF-Q180 used for esophagogastroduodenoscopy, the CF-Q180 used for colonoscopy, and the TJF-Q180 used for ERCP (Olympus America Inc., Center Valley, Pennsylvania). Under three different clinical gas insufflation scenarios, we measured in vitro maximum gas pressure transduced from a closed space created at the endoscope tip in a worst-case scenario analysis. Results We showed that it is readily possible to generate a pressure (>5-30 times normal central venous pressure) in the air space at the tip of all three endoscopes when insufflation is activated and the gas egress is limited. Conclusions These findings shed additional light on in vivo occurrences of gas embolism during gastrointestinal endoscopy. We postulate that in addition to using exclusively CO2 as the insufflating gas, the risk of gas embolism can be further diminished by regulating insufflating gas pressure at the tip of endoscopes.
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Kumari P, Machhan P, Sharma B, Sharma R, Bodh V, Kumar R. Dyspepsia with alarm symptoms in patients aged less than 60 years: Is upper gastrointestinal endoscopy justified in Indian scenario? Indian J Gastroenterol 2022; 41:430-439. [PMID: 36308702 DOI: 10.1007/s12664-022-01275-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/26/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Newer American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal (GI) neoplasia. The validity of this recommendation has not been evaluated in our population. So, this study was conducted to assess the utility of upper GI endoscopy to investigate alarm features in dyspepsia patients less than 60 years of age to exclude upper GI neoplasia. METHODS This prospective observational study evaluated consecutive patients of dyspepsia between 18 and 60 years of age, with at least one or more of the alarm symptoms (unintentional weight loss; loss of appetite; GI bleeding; anemia; recurrent or persistent vomiting; dysphagia with predominant epigastric pain; and family history of upper GI cancer) with upper GI endoscopy to exclude any organic lesion and malignancy. RESULTS Of total 294 patients evaluated with endoscopy, 34.7% (n=102) had normal endoscopy (functional dyspepsia [FD]) while 65.3% (n=192) had abnormal endoscopic findings (organic dyspepsia [OD]). Of 192 patients with OD, 146 patients (49.6% of the total study population) had benign abnormality (benign OD) while 46 patients (15.6% of the total study population) had malignancy of the upper GI tract (malignant OD). CONCLUSION The investigation of alarm features in dyspepsia patients less than 60 years of age with upper GI endoscopy leads to detection of organic lesion (65.3%) including malignancy (15.6%) in a significant percentage of patients.
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Affiliation(s)
- Priya Kumari
- Department of Medicine, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Prem Machhan
- Department of Medicine, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Rajesh Sharma
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India.
| | - Rajesh Kumar
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
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Maiti S, Congly SE, Ma C, Olympia-Sy K, Hardcastle L, Stapleton MP, Forbes N. Causes and Outcomes of Medicolegal Proceedings Following Gastrointestinal Endoscopy in Canada. GASTRO HEP ADVANCES 2022; 2:163-169. [PMID: 39132606 PMCID: PMC11308791 DOI: 10.1016/j.gastha.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims Endoscopic procedures are frequently performed in Canada but can be associated with potential complications and medicolegal implications. This study aimed to identify potential medicolegal cases in Canada relating to upper and lower endoscopies as well as advanced endoscopic procedures. Methods Westlaw Canada was searched for any cases regarding upper and lower endoscopies and advanced endoscopic procedures from inception to December 31, 2020. Cases were classified by type of case, procedure performed, patient and defendant demographics, outcome, and alleged reason for litigation/complaint. Results Twenty-nine civil cases and 9 board and tribunal decisions for upper and lower endoscopies and 3 advanced endoscopic procedure cases were analyzed. The most frequent defendant specialties were family physician, general surgery, and gastroenterology. The plaintiff was successful in 12 cases involving upper or lower endoscopy with an average award of $243,934 (2021 CDN). The most alleged reasons for litigation were procedural error or negligence (n = 19). The plaintiff was successful in 1 advanced endoscopic procedure case with an award of $153,032. Conclusion Medicolegal cases regarding gastrointestinal endoscopy in Canada occur infrequently. Endoscopy should be performed by skilled providers with appropriate informed consent from the patient, and careful consideration of whether procedures are indicated are key for endoscopic providers.
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Affiliation(s)
- Souvik Maiti
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Lorian Hardcastle
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Faculty of Law, University of Calgary, Calgary, Alberta, Canada
| | - Melanie P. Stapleton
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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50
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Adverse events associated with EGD and EGD-related techniques. Gastrointest Endosc 2022; 96:389-401.e1. [PMID: 35843754 DOI: 10.1016/j.gie.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
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