Use of an Ultra-slim Gastroscope to Accomplish Endoscopist-Facilitated Rescue Intubation During ERCP: A Novel Approach to Enhance Patient and Staff Safety.

BACKGROUND: ERCP is often performed under monitored anesthesia care (MAC) rather than general anesthesia (GA), with patients positioned semi-prone on the fluoroscopy table. Rarely, a MAC ERCP must be converted to GA due to hypoxia or retained food in the stomach. In these circumstances, standard intubation is associated with a significant delay and potential for patient/staff injury during repositioning. We report a novel endoscopist-driven approach to intubation during ERCP using an ultra-slim, flexible gastroscope with an endotracheal tube backloaded onto it. MATERIALS AND METHODS: We identified patients who underwent ERCP from 2014 to 2019, and MAC to GA conversion events. Mode of intubation (standard vs. endoscopist-facilitated) and patient/procedure characteristics were evaluated. All endoscopist-facilitated intubations were performed under anesthesiologist supervision. RESULTS: A total of 3409 patients underwent ERCP; 1568 (46%) GA and 1841 (54%) MAC. Of these, 42 (2.3%) required intubation during ERCP and 16 underwent endoscopist-facilitated intubation due to retained food in the stomach and/or hypoxia. In 3 patients, aspirated material was suctioned from the trachea and bronchi using the ultra-slim gastroscope. Immediate post-procedure extubation was successful in all endoscopist-facilitated intubation patients and none exhibited radiographic evidence of aspiration pneumonia. CONCLUSIONS: Endoscopist-facilitated intubation using an ultra-slim flexible gastroscope is feasible and expeditious for MAC to GA conversion during ERCP. This technique is readily accomplished in the semi-prone position, while standard intubation requires patient transfer from fluoroscopy table to gurney, with associated delay/risks. These data suggest that further study of this approach is warranted, and this may be the most favorable approach for intubation during ERCP.

Improving All-Cause Inpatient Mortality After Percutaneous Endoscopic Gastrostomy.

BACKGROUND AND AIMS: Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients. METHODS: A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample. RESULTS: A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201). CONCLUSIONS: Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.

Clinical observation of the combined use of propofol and etomidate in painless gastroscopy.

OBJECTIVE: This study is aims to compare the anesthetic safety of propofol combined with etomidate for painless gastroscopy. METHODS: Three hundred patients undergoing painless gastroscopy were randomly assigned to P, PE1, and PE2 groups. Patients were anesthetized with propofol (P group) or propofol combined with etomidate (volume ratio 1: 1, PE1 group; volume ratio 2: 1, PE2 group). The hemodynamics and adverse reactions were observed. The sleep quality satisfaction and nature of dreams were recorded. RESULTS: Compared with pre-anesthesia, the mean arterial pressure and heart rate of the 3 groups were significantly slower during the examination and at the end of the examination. PE1 group had a higher incidence of muscle spasm, body moving, choking, and deglutition. The incidence of hypoxemia and injection pain was higher in P group. P and PE2 group had higher sleep quality satisfaction and dream incidence after awaking. However, there was no difference in the nature of dreams among 3 groups. CONCLUSION: Our data indicate that the combination of 10 ml 1.0% propofol and 5 ml 0.2% etomidate for painless gastroscopy reduces adverse reactions while not affecting the patients respiratory function. Moreover, it is safe and effective, which is worthy of clinical application and promotion.

Evaluation of endoscopy requests in the resumption of activity during the SARS-CoV-2 pandemic: denial of nonindicated requests and prioritization of accepted requests.

INTRODUCTION: the global SARS-CoV-2 pandemic forced the closure of endoscopy units. Before resuming endoscopic activity, we designed a protocol to evaluate gastroscopies and colonoscopies cancelled during the pandemic, denying inappropriate requests and prioritizing appropriate ones. METHODS: two types of inappropriate request were established: a) COVID-19 context, people aged ≤ 50 years without alarm symptoms and a low probability of relevant endoscopic findings; and b) inappropriate context, requests not in line with clinical guidelines or protocols. Denials were filed in the medical record. Appropriate requests were classified into priority, conventional and follow-up. Requests denied by specialty were compared and the findings of priority requests were evaluated. RESULTS: between March 16th and June 30th 2020, 1,658 requests (44 % gastroscopies and 56 % colonoscopies) were evaluated, of which 1,164 (70 %) were considered as appropriate (priority 8.5 %, conventional 48 %, follow-up 43 % and non-evaluable 0.5 %) and 494 (30 %) as inappropriate (20 % COVID-19 context, 80 % inappropriate context). The reasons for denial of gastroscopy were follow-up of lesions (33 %), insufficiently studied symptoms (20 %) and relapsing symptoms after a previous gastroscopy (18 %). The reasons for denial of colonoscopies were post-polypectomy surveillance (25 %), colorectal cancer after surgery (21 %) and a family history of cancer (13 %). There were significant differences in denied requests according to specialty: General Surgery (52 %), Hematology (37 %) and Primary Care (29 %); 31 % of priority cases showed relevant findings. CONCLUSIONS: according to our study, 24 % of endoscopies were discordant with scientific recommendations. Therefore, their denial and the prioritization of appropriate ones optimize the use of resources.

Gastric per-oral endoscopic myotomy: Current status and future directions.

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.

Clinical application of magnetically controlled capsule gastroscopy in gastric disease diagnosis: recent advances.

Magnetically controlled capsule gastroscopy (MCCG) is a novel system primarily used for the diagnosis of gastric disease. It consists of an endoscopic capsule with magnetic material inside, external guidance magnet equipment, data recorder and computer workstation. Several clinical trials have demonstrated that MCCG is comparable in accuracy in diagnosing gastric focal disease when compared to conventional gastroscopy. Further clinical studies are needed to test the diagnostic accuracy and improve the functioning of MCCG. This novel MCCG system could be a promising alternative for screening for gastric diseases, with the advantages of no anesthesia required, comfort and high acceptance across populations.

Adoption of evidence-based novel therapies in the treatment of gastric cancer: A national observational study.

BACKGROUND: The adoption of novel and effective gastric cancer therapies into general clinical practice has crucial implications for patient outcomes. The current study explored trends in treatment use and overall survival in patients with gastric cancer in the United States. METHODS: Patients with adenocarcinoma of the gastric cardia and noncardia were identified in the National Cancer Data Base between 2006 and 2014. Tumor stages were divided into early (IA), locally advanced (IB-IIIC), and metastatic (IV) stage. Treatment use was examined according to tumor stage and location. Time trend analyses of treatment use and overall survival were conducted. RESULTS: A total of 89,098 patients with gastric adenocarcinoma were identified. In those with early-stage cancer, endoscopic treatment increased over time in patients with cardia and noncardia disease. In patients with locally advanced cardia disease, preoperative therapy use increased over time (2013-2014 [vs 2006-2008]: odds ratio [OR], 3.09; 95% confidence interval [95% CI], 2.80-3.41). In patients with locally advanced noncardia disease, the use of preoperative therapy also increased (2013-2014: OR, 3.32; 95% CI, 2.88-3.82) as did the use of perioperative therapy (2013-2014: OR, 4.21; 95% CI, 3.52-5.03) in lieu of postoperative treatment (2013-2014: OR, 0.66; 95% CI, 0.60-0.71). In patients with metastatic disease, approximately 34% of patients with cardia and 40% of patients with noncardia cancer did not receive treatment. Stage-specific and location-specific overall survival was found to improve over the study period. CONCLUSIONS: Practice patterns for the treatment of gastric cancer in the United States reflect the increased adoption of evidence-based therapies, including endoscopic resection of early-stage cancer and preoperative therapy for patients with locally advanced disease. Treatment for metastatic disease remains markedly underused. Cancer 2018;124:1122-31. © 2017 American Cancer Society.

Advances in endoscopic balloon therapy for weight loss and its limitations.

The field of medical and surgical weight loss is undergoing an explosion of new techniques and devices. A lot of these are geared towards endoscopic approaches rather than the conventional and more invasive laparoscopic or open approach. One such recent advance is the introduction of intrgastric balloons. In this article, we discuss the recently Food and Drug Administration approved following balloons for weight loss: the Orbera™ Intragastric Balloon System (Apollo Endosurgery Inc, Austin, TX, United States), the ReShape® Integrated Dual Balloon System (ReShape Medical, Inc., San Clemente, CA, United States), and the Obalon (Obalon® Therapeutics, Inc.). The individual features of each of these balloons, the method of introduction and removal, and the expected weight loss and possible complications are discussed. This review of the various balloons highlights the innovation in the field of weight loss.

Practice Patterns of Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Stroke: Are the Guidelines Achievable?

OBJECTIVES: Our objectives were to evaluate trends in percutaneous endoscopic gastrostomy (PEG) tube placement rate and timing in acute stroke patients. We hypothesized that noncompliance with clinical practice guidelines for timing of tube placement and an increase in placement occurred because of a decrease in length of hospital stay. METHODS: We conducted a retrospective observational study of archival hospital billing data from the Florida state inpatient healthcare cost and utilization project database from 2001 to 2012 for patients with a primary diagnosis of stroke. Outcome measures were timing of PEG tube placements by year (2006-2012), rate of placements by year (2001-2012), and length of hospital stay. Univariate analyses and simple and multivariable logistic regression analyses were conducted. RESULTS: The timing of gastrostomy tube placement remained stable with a median of 7 days post admission from 2006 through 2012. The proportion of tubes that were placed at or after 14 days and thereby met the guideline recommendations varied from 14.09% in 2006 to 13.41% in 2012. The rate of tube placement in stroke patients during the acute hospital stay decreased significantly by 25% from 6.94% in 2001 to 5.22% in 2012 (P < .0001). The length of hospital stay for all stroke patients decreased over the study period (P < .0001). CONCLUSIONS: The vast majority of PEG tube placements happen earlier than clinical practice guidelines recommend. Over the study period, the rate of tubes placed in stroke patients decreased during the acute hospital stay despite an overall reduced length of stay.

Trends regarding percutaneous endoscopic gastrostomy: A nationwide population-based study from 1997 to 2010.

Percutaneous endoscopic gastrostomy (PEG) is widely used in patients requiring long-term tube feeding. Traditional PEG studies usually focused on practical, technical, and ethical issues. There have been little epidemiological studies on PEG utilization and services in Asia. We evaluated the changes in PEG utilization, patient selection, patient characteristics, and medical service in Taiwan from 1997 to 2010.This retrospective study analyzed the data of patients admitted for PEG tube placement according to the International Classification of Diseases, Ninth Revision (procedure code 43.11) extracted from the National Health Insurance database between 1997 and 2010.From 1997 to 2010, the incidence of PEG increased from 0.1 to 3.8/10 population and incidence of PEG among aged patients increased from 0.9 to 19.0/10 population. Compared 1997-2004 to 2005-2010 periods, the percentage of cerebrovascular diseases decreased and esophageal cancer increased in the later period. PEG was mainly performed in male patients and at medical centers. Medical costs, Charlson Comorbidity Index (CCI) scores, and post-PEG mortality rates were higher in the 2005-2010 period than in the 1997-2004 period.PEG procedures are being increasingly performed in Taiwan, and changes in patient selection were noted. The seriousness of accompanying diseases, medical costs, and post-PEG mortality rates in patients undergoing PEG has increased. The present findings may help in the implementation of PEG, relocation of medical resources, and improvement of PEG-related care.

Ever-changing endoscopic treatment for early gastric cancer: yesterday-today-tomorrow.

Endoscopic resection has been an optimal treatment for selected patients with early gastric cancer (EGC) based on advances in endoscopic instruments and techniques. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC along with expanding ESD indication, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Recently, new techniques including ESD or endoscopic full-thickness resection combined with sentinel node navigation enable minimal tumor resection and a laparoscopic lymphadenectomy in cases of EGC with high risk of LNM. This review covers the development and challenges of endoscopic treatment for EGC. Moreover, a new microscopic imaging and endoscopic techniques for precise endoscopic diagnosis and minimally invasive treatment of EGC are introduced.

Endoscopic treatment: the past, the present and the future.

The obesity epidemic asks for an active involvement of gastroenterologists: many of the co-morbidities associated with obesity involve the gastrointestinal tract; a small proportion of obese patients will need bariatric surgery and may suffer from surgical complications that may be solved by minimally invasive endoscopic techniques; and finally, the majority will not be eligible for bariatric surgery and will need some other form of treatment. The first approach should consist of an energy-restricted diet, physical exercise and behaviour modification, followed by pharmacotherapy. For patients who do not respond to medical therapy but are not or not yet surgical candidates, an endoscopic treatment might look attractive. So, endoscopic bariatric therapy has a role to play either as an alternative or adjunct to medical treatment. The different endoscopic modalities may vary in mechanisms of action: by gastric distension and space occupation, delayed gastric emptying, gastric restriction and decreased distensibility, impaired gastric accommodation, stimulation of antroduodenal receptors, or by duodenal exclusion and malabsorption. These treatments will be discussed into detail.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system.

BACKGROUND/AIM: Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system. PATIENTS AND METHODS: A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis. RESULTS: A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),''persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively. CONCLUSION: A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected.

Outcome of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis in relation to respiratory dysfunction.

Our objective was to describe a group of ALS patients who underwent percutaneous endoscopic gastrostomy (PEG) insertion, with emphasis on the respiratory function, by comparing patients with forced vital capacity (FVC) > 30% versus FVC ≤ 30%, and the effect of respiratory dysfunction on the perioperative complication rate and survival. Thirty consecutive ALS patients in whom FVC status was known underwent PEG insertion at our centre. Twenty of them had FVC > 30% (50.1% ± 20) at the time of the procedure, and 10 had FVC ≤ 30% (20.1% ± 7). Demographic and clinical data were reviewed in each patient. Results showed that all patients had successful PEG insertion without any complications. There was no statistically significant difference between the two FVC groups regarding survival after the date of PEG insertion. In conclusion, in this relatively small patient sample there was no difference in complication rate and survival after PEG insertion between patients with poor respiratory function (FVC ≤ 30%) at the time of the procedure and patients with better respiratory function (FVC > 30%). Therefore, according to our data, PEG insertion may be regarded as safe even in patients with low FVC and should be offered even to patients with respiratory dysfunction.

Basic geriatric assessment does not predict in-hospital mortality after PEG placement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement. METHODS: All patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality. RESULTS: A total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group 'miscellaneous disease' (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in-hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650). CONCLUSION: In a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.

The over-the-scope clip system--a novel technique for gastrocutaneous fistula closure: the first North American experience.

BACKGROUND: The mainstay of therapy for gastrocutaneous (GC) fistulas has been surgical intervention. However, endoclips are currently used for management of perforations and fistulas but are limited by their ability to entrap and hold the tissue. OBJECTIVE: To report the first North American experience with a commercially available over-the-scope clip (OTSC) device, a novel and new tool for the endoscopic entrapment of tissue for the closure of fistula and perforations. METHODS: The present single-centre study was conducted at a tertiary referral academic gastroenterology unit and centre for advanced therapeutic endoscopy and involved patients referred for endoscopic treatment for the closure of a GC fistula. The OTSC device was mounted on the tip of the endoscope and passed into the stomach to the level of the fistula. The targeted site of the fistula was grasped with the tissue anchoring tripod and pulled into the cap with concomitant scope channel suction. Once the tissue was trapped in the cap, a 'bear claw' clip was deployed. RESULTS: The patients recovered with fistula closure. No complication or recurrence was noted. Fistula sizes >1 cm, however, were difficult to close with the OTSC system. The length of stay of the bear claw clip at the fistula site is unpredictable, which may lead to incomplete closure of the fistula. CONCLUSION: Closure of a GC fistula using a novel 'bear claw' clip system is feasible and safe.

Surgery via natural orifices in human beings: yesterday, today, tomorrow.

BACKGROUND: We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. METHODS: Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated. RESULTS: The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable. CONCLUSIONS: NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.