Endoscopic complications--avoidance and management

Prediction of esophagogastroduodenoscopy therapeutic usefulness for in-ICU suspected upper gastrointestinal bleeding: the SUGIBI score study

BACKGROUND

Suspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB.

METHODS

We conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort.

RESULTS

Two hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91-99) for hemostatic endotherapy [AUC of 0.81; 0.75-0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66-0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92-97).

CONCLUSIONS

Our study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD.

Patient participation in gastrointestinal endoscopy - From patients' perspectives

Background

Patient participation is associated with satisfaction and improved health‐related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.

Objective

To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.

Methods

Semi‐structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19‐80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.

Results

Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff ‘invited’ patients in decision making.

Discussion

This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.

Conclusions

Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.

Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group

BACKGROUND AND AIM

In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia.

METHODS

A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI² G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements.

RESULTS

Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology.

CONCLUSION

This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.

Endoscopic transpapillary drainage in disconnected pancreatic duct syndrome after acute pancreatitis and trauma: long-term outcomes in 31 patients

Background

Conventionally, disconnected pancreatic duct syndrome is treated surgically. Endoscopic management is associated with lesser morbidity and mortality than that observed with surgery and shows similar success rates. However, limited data are available in this context. We evaluated the efficacy of endotherapeutic management for this syndrome.

Methods

We prospectively obtained data of patients with disconnected pancreatic duct syndrome between September 2008 and January 2016. Demographic and clinical data were assessed, and factors affecting clinical outcomes were statistically analyzed.

Results

Thirty-one patients underwent 40 endoscopic transpapillary procedures, and 1 patient developed an infection after prosthesis insertion. Etiological contributors to disconnected pancreatic duct syndrome were abdominal trauma (52%) and acute necrotizing pancreatitis (48%). The median interval between the appearance of pancreatic leaks and disconnected pancreatic duct syndrome was 6.6 months (range 0.5–84 months). The median follow-up after the last treatment procedure was 38 months (range 17–99 months). Patients with complete main pancreatic duct disruption in the body/tail showed a low risk of pancreatic atrophy (P = 0.009). This study highlighted the significant correlation between endoscopic transpapillary drainage and clinical success (P = 0.014).

Conclusions

Disconnected pancreatic duct syndrome is not an uncommon sequel of pancreatic injury, and much of the delayed diagnosis is attributable to a lack of knowledge regarding this disease. Endoscopic transpapillary intervention with ductal stenting is an effective and safe treatment for this condition.

Endoscopic Ultrasound-Guided Rendezvous Procedure for a Nondilated, Leaking Pancreatic Duct

Pancreatic duct (PD) leak leading to pancreatic ascites is a serious complication of chronic pancreatitis. Endoscopic management with endoscopic retrograde cholangiopancreatography (ERCP) has been found to be successful; however, if selective cannulation of the PD is unsuccessful, an endoscopic ultrasound–guided rendezvous procedure can help in bridging PD leaks, provided the duct is dilated. We report a successful endoscopic ultrasound–guided rendezvous procedure in a patient with PD leak, pancreatic ascites, and a nondilated duct with failed ERCP who was a poor candidate for surgery. The pancreatic ascites resolved following the procedure.

Current clinical algorithms for predicting common bile duct stones have only moderate accuracy

BACKGROUND AND AIM

A risk-stratified approach for selecting patients likely to harbor common bile duct (CBD) stones to proceed directly to endoscopic or surgical stone clearance, rather than undergo less invasive testing, has been proposed. We assessed the performance of three clinical algorithms used to predict CBD stones.

METHODS

All patients undergoing first-time endoscopic retrograde cholangiopancreatography (ERCP) in 2011-2012 as a result of suspected CBD stones were enrolled prospectively in a clinical database. Data such as imaging test findings and liver function tests (LFTs) were collected 48 h prior to and on the day of ERCP. Patients were stratified into different risk groups for harboring CBD stones according to three clinical algorithms using imaging and laboratory data. Findings on ERCP were used as gold standard. Performance characteristics of each algorithm were separately calculated for each time point of LFT assessment.

RESULTS

Overall, 186 patients were analyzed, 75% of whom presented CBD stones on ERCP. Proportion of patients categorized as high-risk for harboring CBD stones varied among the three algorithms (67% vs 73% vs 56%). Also, the algorithms showed only moderate, albeit comparable, accuracy for predicting the presence of CBD stones (0.65, 95% confidence interval [CI] 0.62-0.68 vs 0.68, 95% CI 0.63-0.67 vs 0.59, 95% CI 0.57-0.61). Similar results were obtained when performance characteristics were recalculated using LFT from 48 h prior to ERCP (data not shown).

CONCLUSION

Three diagnostic algorithms commonly used for predicting CBD stones have comparable but only moderate accuracy. Further research is warranted to improve risk stratification of patients with suspected CBD stones.

Person-centered endoscopy safety checklist: Development, implementation, and evaluation

AIM

To describe the development and implementation of a person-centered endoscopy safety checklist and to evaluate the effects of a “checklist intervention”.

METHODS

The checklist, based on previously published safety checklists, was developed and locally adapted, taking patient safety aspects into consideration and using a person-centered approach. This novel checklist was introduced to the staff of an endoscopy unit at a Stockholm University Hospital during half-day seminars and team training sessions. Structured observations of the endoscopy team’s performance were conducted before and after the introduction of the checklist. In addition, questionnaires focusing on patient participation, collaboration climate, and patient safety issues were collected from patients and staff.

RESULTS

A person-centered safety checklist was developed and introduced by a multi-professional group in the endoscopy unit. A statistically significant increase in accurate patient identity verification by the physicians was noted (from 0% at baseline to 87% after 10 mo, P < 0.001), and remained high among nurses (93% at baseline vs 96% after 10 mo, P = nonsignificant). Observations indicated that the professional staff made frequent attempts to use the checklist, but compliance was suboptimal: All items in the observed nurse-led “summaries” were included in 56% of these interactions, and physicians participated by directly facing the patient in 50% of the interactions. On the questionnaires administered to the staff, items regarding collaboration and the importance of patient participation were rated more highly after the introduction of the checklist, but this did not result in statistical significance (P = 0.07/P = 0.08). The patients rated almost all items as very high both before and after the introduction of the checklist; hence, no statistical difference was noted.

CONCLUSION

The intervention led to increased patient identity verification by physicians - a patient safety improvement. Clear evidence of enhanced person-centeredness or team work was not found.

The role of surgery in the treatment of endoscopic complications

As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped that this review will provide guidance for gastroenterologists considering a particular procedure, either to assess the risks for surgical complications in preparation for patient counseling, or assist in assessing a patient who seems to be having a severe complication, or to learn what operation might be required to treat a given complication and how that operation might be performed. As with many operations, those for the treatment of endoscopic complications are typically performed only when less invasive, nonoperative strategies fail.

Upper gastrointestinal endoscopy: expected post-procedural findings and adverse events

Complications related to endoscopy are commonly encountered in the emergency department (ED) due to an increased use of outpatient diagnostic and therapeutic upper gastrointestinal endoscopic procedures. A majority of these procedures are performed on an outpatient basis, and patients with post-procedural symptoms may return to the ED. Since these patients often undergo computed tomography (CT) for diagnosis of post-procedure complications, the emergency radiologist should be familiar with the spectrum of expected post-procedural findings, as well as common and rare complications. We present a pictorial review of post-endoscopy complications and review imaging protocols in different clinical scenarios.

Endoscopic prediction of recurrence in patients with early gastric cancer after margin-negative endoscopic resection

BACKGROUND AND AIM

Although follow-up endoscopy is routinely performed after endoscopic resection (ER) for early gastric cancer (EGC), it remains unclear whether resection scar biopsies should also be taken. This study sought to predict local recurrence at the ER scar on the basis of endoscopic criteria after margin-negative EGC resection and to determine the necessity of taking scar biopsies.

METHODS

All consecutive patients with EGC who underwent margin-negative ER in June 1995 to December 2011 and developed recurrence at the scar were identified. Each case was matched by four controls with EGC and margin-negative ER but without local recurrence for age, sex, and en-bloc resectability (en-bloc vs. piecemeal resection). Endoscopic data were reviewed by consensus of two endoscopists. Key endoscopic criteria were gross morphology (evenly elevated, unevenly elevated, and flat), hyperemic change, mucosal defect, and spontaneous bleeding.

RESULTS

Of 3037 cases, which underwent margin-negative ER, 22 developed local recurrence (mean age, 63.8 years; 72.9% male). En-bloc resection was achieved in 20 of the 22 (90.9%). Flat endoscopic morphology without hyperemic changes predicted non-recurrence at the scar with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 95.5%, 68.2%, 2.6%, 99.94%, and 73.6%, respectively. For patients who underwent en-bloc resection for differentiated EGC, these values were 100%, 71.4%, 3.0%, 100%, and 75.8%, respectively.

CONCLUSIONS

Routine follow-up biopsies may be unnecessary when follow-up endoscopy reveals flat mucosa without hyperemic changes at the scar, especially for en-bloc resected and differentiated EGCs.

[Management of complications in endoscopic interventions of the upper gastrointestinal tract]

Endoscopic procedures are frequently performed interventions in the clinical routine. Whereas endoscopy was initially regarded as being a secondary diagnostic tool, over the last decades endoscopic procedures have now become an integral part of various treatment strategies. The appeal of these methods is without any doubt the minimally invasive approach in contrast to open surgery. Endoscopic interventions per se necessitate representative technical equipment and the various components are continually being refined. Considering the complexity of the method, profound skills in endoscopic diagnostic procedures and therapeutic interventions are essential prerequisites for adequate procedural quality and patient safety. Endoscopic examinations are in fact invasive interventions in the same way as surgical procedures and are associated with a certain risk of potential complications. The awareness about potential complications and their respective risk factors is of crucial importance for both the patient and the physician. Complications may harm patients and may lead to increased mortality rates; therefore, it is not only important to be aware of them but also to have an efficient management strategy in order to minimize the damage. Recognition and consistent actions are the basic pillars of correct complication management. These aspects are addressed in this article.

The impact of chronic opioid use on colonoscopy outcomes

BACKGROUND

Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation.

AIMS

We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects.

METHODS

This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times.

RESULTS

Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002).

CONCLUSION

Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

Endoscopic therapy for pancreatic duct leaks and disruptions

Pancreatitis, whether acute or chronic, can lead to a plethora of complications, such as fluid collections, pseudocysts, fistulas, and necrosis, all of which are secondary to leakage of secretions from the pancreatic ductal system. Partial and side branch duct disruptions can be managed successfully by transpapillary pancreatic duct stent placement, whereas patients with disconnected pancreatic duct syndrome require more complex endoscopic interventions or multidisciplinary care for optimal treatment outcomes. This review discusses the current status of endoscopic management of pancreatic duct leaks and emerging concepts for the treatment of disconnected pancreatic duct syndrome.