Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol.

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.

Outcomes of colon self-expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature.

BACKGROUND: Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement. AIM: To review long- and short-term clinical success of SEMS use for colonic obstruction at our center. METHODS: We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded. RESULTS: Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS). CONCLUSION: Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.

Electronic Health Record Work Demands for Gastroenterology and Hepatology Providers: A Prospective Use Analysis and Survey Study.

BACKGROUND AND AIMS: There is a paucity of research on the use of the electronic health record (EHR) by gastroenterology and hepatology providers and its effect on work-life balance. Our aim was to study the after-hour EHR work completed among providers within a multispecialty academic practice. METHODS: Time spent completing EHR tasks during evening hours (7p-7a) and days off was prospectively recorded for 35 providers over six consecutive months at a single center. Type and time of EHR tasks completed were compared based on subspecialty, academic degree, academic track category, identified gender, and number of weekly assigned clinical days worked. Prior to the data collection, providers filled out a survey regarding EHR use, work hours, and work-life balance. RESULTS: All providers used EHR during evening hours and during days off. The total mean after-hours time spent completing EHR tasks was 18.4 m (± 13.0) per day and 45.0 m (± 25.8) during days off. There was significant variation in the daily mean after-hours time spent completing EHR tasks among subspecialties, range 45.3 m (± 27.1) (advanced endoscopy)-28.7 m (± 22.7) (hepatology), and among providers who work clinically > 7.5 days per week versus those who do not, 42.1 m (± 25.7) vs 30.0 m (± 14.0). The most common after-hours EHR task was note completion. 83% providers reported being unable to complete EHR tasks during allotted workday time and 87% report that EHR tasks interfered with family life; 74% with social life. CONCLUSION: Gastroenterology and hepatology providers spend a significant amount of after-hour time completing EHR tasks which is perceived to interfere with family/social life.

What lies in-between: C3 glomerulopathy with non-hemolytic renal microangiopathy and an ultra-rare C3 variant.

We report a 36-year-old female with mixed nephritic-nephrotic syndrome and recurrent pancreatitis. Kidney biopsy showed a crescentic membranoproliferative glomerulonephritis with dominant C3 staining on immunofluorescence (IF) but only scant deposits on electron microscopy (EM) and instead, evidence of severe acute and chronic microangiopathy - endothelial swelling, sub-endothelial fluff, and segmental basement membrane remodeling. Her serum C3 was normal, Factor Ba, and serum Membrane attack complex (sMAC) levels were elevated, and Properdin was low. Genetic testing revealed a heterozygous ultra rare C3 variant of unknown significance (c.4838G>T, p.Gly1613Val) as well as a heterozygous deletion of CFHR3-CFHR1. She showed an initial response to terminal complement blockade with eculizumab, but her renal disease progressed in the next year. Notably, our patient never demonstrated microangiopathic hemolysis, yet pancreatitis of unclear etiology recurred periodically. Our case suggests the existence of a "C3G/aHUS overlap" clinicopathologic syndrome and highlights the challenges of treating complement-mediated kidney disease.

Retrograde Balloon-Assisted Deep Enteroscopy in the Diagnosis of Metastatic Melanoma.

A 74-year-old male with a history of metastatic melanoma presents with persistently abnormal small bowel findings on PET-CT scan. The patient had persistent FDG uptake near the ileocolic junction on imaging, concerning for metastatic melanoma. Capsule endoscopy demonstrated ulcerated mucosa in the distal ileum. This area was biopsied and tattooed via retrograde double-balloon enteroscopy to confirm the diagnosis of metastatic melanoma and facilitate subsequent small bowel resection. The case illustrates a unique case of metastatic melanoma to the small bowel and the utility of capsule endoscopy and balloon-assisted enteroscopy to assist in diagnosis and management of metastatic disease.

Percutaneous Transhepatic Single-Operator Cholangioscopy-Guided Intraductal Stone Therapy in a Liver Transplant Patient With Ischemic Cholangiopathy.

Ischemic cholangiopathy is a feared complication after liver transplantation. We present a 68-year-old man who is status postorthotopic liver transplant from a donation after cardiac death. His posttransplant course was complicated by the development of a biliary anastomotic stricture, ischemic cholangiopathy, biloma, recurrent cholangitis, and intrahepatic stones. Through the use of antegrade cholangioscopy with a single-operator cholangioscope (SpyGlass 2; Boston Scientific, Boston, MA) passed through a percutaneous sheath, we were able to visualize impacted stones within the left intrahepatic system and treat them using electrohydraulic lithotripsy for stone fragmentation and removal.

Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP).

Objectives: Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. Methods: A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. Results: A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. Conclusions: Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance.

Safety and Efficacy of Moderate Sedation in Super Obese Patients Undergoing Lower and Upper GI Endoscopy: a Case-Control Study.

PURPOSE: Obesity is a disease of increasing prevalence. There is minimal research on the safety of sedation for general endoscopic procedures among super obese patients (BMI ≥ 50). The aim of our study was to evaluate the safety of moderate sedation and endoscopic procedural outcomes for super obese patients in a case-control study. MATERIALS AND METHODS: We completed an age and sex-matched case-control study comparing 132 super obese patients with 132 non-obese controls. We assessed intra-procedure adverse events, delayed adverse events, doses of sedation medication used, and procedure duration at a tertiary care setting. RESULTS: The mean BMI for the obese cohort was 55.6 compared with 22.5 for the controls (P < 0.001). The mean intra-procedure fentanyl and midazolam dose was higher for the obese patients compared with the controls, fentanyl 180 mcg, midazolam 7.7 mg vs fentanyl 148 mcg, midazolam 6.4 mg, respectively (P < 0.001). There was a significantly higher percentage of brief intra-procedure hypoxia (oxygen blood saturation < 90%) for the obese patients compared with the controls, 5% vs 0% (P = 0.02). There was no difference in delayed adverse events with 2% of the cases and 2% of the controls having delayed adverse events (P = 1.0). Procedure completion rates were 100% for both cases and controls. CONCLUSION: General endoscopic procedures can be safely and effectively performed in super obese patients with moderate sedation. Brief intra-procedure hypoxia more commonly occurs in super obese patients, and higher medication doses are required.

Endoscopic Ultrasound in Guiding Local Resection and Ampullary Preservation of a High-Risk Periampullary GIST.

Gastrointestinal stromal tumors (GISTs) typically develop in the stomach or small intestine and rarely involve the ampulla of Vater, with only 13 cases reported in the world literature since 2004. Most authors advocate performing pancreaticoduodenectomy for such lesions. However, this operation can carry higher rates of morbidity and mortality compared to local resection. We present a case of a high-risk, invasive periampullary GIST and the multidisciplinary management approach to local resection with the aid of endoscopic ultrasound. In addition, this case shows no local recurrence at 3 months and a favorable clinical outcome at 1 year.

Trends in Wait Time for Colorectal Cancer Screening and Diagnosis 2013-2016.

OBJECTIVES: Colorectal cancer (CRC) screening has increased in the United States during the past 20 years, resulting in an increased demand for colonoscopy. We tested the hypothesis that such increase resulted in longer wait times for colonoscopy and influenced CRC diagnosis. METHODS: A total of 36,623 consecutive colonoscopies performed at the University of Wisconsin from April 8, 2013, until December 31, 2016, were included in the analysis. Wait times for colonoscopy were stratified by consecutive 6-month periods and indications of screening/surveillance vs diagnostic colonoscopy. RESULTS: Despite unchanged number of endoscopists, more colonoscopies were performed in 2015-2016 than in 2013-2014 (20,897 vs 15,726, respectively, P = 0.004). The mean wait time for colonoscopy increased from 68 days in 2013-2014 to 111 days in 2015-2016 (P < 0.0001), with most change affecting screening/surveillance colonoscopy. In 170 patients with a newly diagnosed CRC, the wait time did not significantly change between 2013-2014 and 2015-2016 (21 vs 27 days, respectively, P = 0.2206). DISCUSSION: An increase in screening/surveillance colonoscopies resulted in a substantial rise in the number of procedures between 2013 and 2016. This increase was associated with longer wait times for screening/surveillance but not diagnostic colonoscopy. Longer wait times did not result in later CRC stage at diagnosis.

A Prospective, Randomized Comparison of Duodenoscope Reprocessing Surveillance Methods.

Duodenoscope use in healthcare facilities has been associated with transmission of multidrug resistant pathogens between patients. To assist healthcare facilities in monitoring the quality of their duodenoscope reprocessing procedures and limit patient risk of infection, the Centers for Disease Control and Prevention (CDC) deployed voluntary interim duodenoscope sampling and culturing surveillance protocols in 2015. Though the interim methods were widely adopted, alternative surveillance protocols were developed and implemented at individual institutions. Here, we compared two sampling methods-the 2015 CDC interim protocol and an alternative protocol developed by the University of Wisconsin Hospitals and Clinics (UWHC). We hypothesized that the UWHC protocol would detect a higher incidence of bacterial contamination from reprocessed duodenoscopes. A total of 248 sampling events were performed at UWHC. The CDC protocol (n = 129 sampling events) required culturing samples collected from each duodenoscope after brushing its terminal end and flushing its lumen with sterile water. The UWHC protocol (n = 119 sampling events) required culturing samples collected from each duodenoscope after swabbing its elevator, immersing its terminal end into broth and flushing its lumen with saline. With the CDC method, 8.53% (n = 11) of the duodenoscopes sampled were positive for bacterial growth with 15 isolates recovered. Using the UWHC method, 15.13% (n = 18) of cultures were positive for bacterial growth with 20 isolates recovered. The relative risk of identifying a contaminated duodenoscope using the CDC interim method, however, was not different than when using the UWHC protocol. Mean processing time (27.35 and 5.11 minutes, p < 0.001) and total cost per sample event ($17.87 and $15.04) were lower using the UWHC method. As the UWHC protocol provides similar detection rates as the CDC protocol, the UWHC method is useful, provided the shorter processing time and lower cost to perform.

Cytology with rapid on-site examination (ROSE) does not improve diagnostic yield of EUS-FNA of pancreatic cystic lesions.

BACKGROUND: Cytology with rapid on-site evaluation (ROSE) has been shown to increase the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions. No data exists on the need for rapid onsite cytology in the evaluation of pancreatic cystic lesions (PCLs). The purpose of this study is to determine whether onsite cytology impacts the diagnostic yield of EUS-FNA of PCLs. METHODS: We prospectively examined all patients with PCLs who underwent EUS-FNA without onsite cytology over a 6-month period and compared this to a historical cohort of patients with PCLs who underwent EUS-FNA with ROSE in the previous 6 months. Comparison was made between the two groups based upon patient demographics, EUS cyst characteristics, and FNA fluid & cytopathology results. RESULTS: A total of 100 EUS-FNA exams for PCLs were identified: 46 with ROSE and 54 without onsite cytology. The majority of cytology findings were negative or nondiagnostic, 87.0% in the ROSE group, 77.8% in the group without onsite cytology. There was no difference using EUS-FNA without onsite cytology compared to ROSE when measuring total diagnostic yield (22.2% vs 13.0%, P = .30), number of nondiagnostic specimens (50% vs 54%, P = .69), and number of needle passes (1.51 vs 1.57, P = .68). CONCLUSIONS: (a) The majority of cytology results from EUS-FNA of cystic lesions are negative or nondiagnostic. (b) Having rapid onsite cytology evaluation of cystic lesions does not affect the number of needle passes nor diagnostic yield and is thus not recommended.

Impact of a novel protocol for atrial fibrillation management in outpatient gastrointestinal endoscopic procedures: a retrospective cohort study.

BACKGROUND: Atrial fibrillation (AF) may result in procedure cancellations and emergency department (ED) referrals for patients presenting for outpatient GI endoscopic procedures. Such cancellations and referrals delay patient care and can lead to inefficient use of resources. METHODS: All consecutive patients presenting in AF for a colonoscopy or upper endoscopy to the University of Wisconsin Digestive Health Center between October 2013 and September 2014 were defined as the pre-intervention group (Group 1). In 2015, a protocol was initiated for peri-procedural management of patients presenting in AF, new onset or previously known. All consecutive patients after initiation of the protocol from October 2015 to September 2016 were analyzed as the post intervention group (Group 2). Patients with heart failure, hypotension, or chest pain were excluded from the protocol. RESULTS: One hundred nine and 141 patients were included in Groups 1 and Group 2, respectively. Following protocol initiation, patients were less likely to present to the ED (6.4% Group 1 vs. 1.4% Group 2, RR 0.22, p = 0.04). There was also a trend towards a reduction in procedure cancelations (5.5% Group 1 vs. 1.4% Group 2, RR 0.26, p = 0.08). All attempted procedures were completed and there were no complications in the intervention group. CONCLUSIONS: Implementation of a standardized protocol for management of atrial fibrillation in patients presenting for outpatient gastrointestinal endoscopic procedures resulted in a significant decrease in emergency department visits with an additional trend toward decreased procedural cancellations without an increased risk of complications.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer.

BACKGROUND AND OBJECTIVES: Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1-T2). METHODS: Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data. RESULTS: There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection. CONCLUSIONS: This study identified only a small number of T1-T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Low Yield and High Cost of Gastric and Duodenal Biopsies for Investigation of Symptoms of Abdominal Pain During Routine Esophagogastroduodenoscopy.

BACKGROUND: Esophagogastroduodenoscopy (EGD) referrals for symptoms of abdominal pain are common. Current guidelines for dyspepsia recommend biopsies of gastric mucosa for Helicobacter pylori in all patients referred for EGD. Our study aimed to determine the clinical yield and cost-effectiveness of gastric and duodenal biopsy in EGDs performed for abdominal pain. METHODS: Three hundred and ninety-one outpatient EGDs performed at a single academic tertiary care center were studied. For each procedure, endoscopic as well as pathologic findings from the stomach and duodenum were then recorded. Charge of biopsy was calculated using the increased charges for professional fees, forceps, and pathology fees when a biopsy was performed. RESULTS: Gastric biopsies were obtained on 304 EGDs performed with 13 (4.2%) patients diagnosed with H. pylori. In patients with abnormal gastric mucosa on EGD, 11 of 167 (6.5%) were positive for H. pylori compared to 2 of 137 (1.4%) with normal appearing mucosa (p = 0.02). Charge per diagnosis of H. pylori for normal mucosa was calculated to be $43,073. Duodenal biopsies were performed in 263 cases. Celiac disease was diagnosed in 4 of 263 cases (1.5%). Of patients with abnormal duodenal mucosa on EGD, 1 of 36 (2.7%) were positive for celiac disease compared to 3 of 227 (1.3%) with normal mucosa (p = 0.57). Charge per diagnosis of celiac disease for normal mucosa was calculated to be $47,580. CONCLUSION: Routine biopsy during EGD for symptoms of abdominal pain has low yield with high costs. Practice of routine biopsies of normal appearing tissue and the present guidelines should be reconsidered in the investigation of abdominal pain with EGD.