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The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.
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This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses effectiveness of endoscopic therapies for the management of pain in CP, including celiac plexus block, endoscopic management of pancreatic duct (PD) stones and strictures, and adverse events such as benign biliary strictures (BBSs) and pseudocysts. In patients with painful CP and an obstructed PD, the ASGE suggests surgical evaluation in patients without contraindication to surgery before initiation of endoscopic management. In patients who have contraindications to surgery or who prefer a less-invasive approach, the ASGE suggests an endoscopic approach as the initial treatment over surgery, if complete ductal clearance is likely. When a decision is made to proceed with a celiac plexus block, the ASGE suggests an EUS-guided approach over a percutaneous approach. The ASGE suggests indications for when to consider ERCP alone or with pancreatoscopy and extracorporeal shock wave lithotripsy alone or followed by ERCP for treating obstructing PD stones based on size, location, and radiopacity. For the initial management of PD strictures, the ASGE suggests using a single plastic stent of the largest caliber that is feasible. For symptomatic BBSs caused by CP, the ASGE suggests the use of covered metal stents over multiple plastic stents. For symptomatic pseudocysts, the ASGE suggests endoscopic therapy over surgery. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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BACKGROUND AND AIMS: Vibration-controlled transient elastography (VCTE) is a validated test for assessing liver fibrosis but may be unreliable in select patients, including those with morbid obesity. The limitations of VCTE may be overcome by EUS-guided shear wave elastography (EUS-SWE). METHODS: This single-center, prospective, nonrandomized tandem study compared the diagnostic accuracy of EUS-SWE and VCTE in consecutive patients undergoing liver biopsy sampling because of unreliable noninvasive testing. EUS-SWE of the left and right lobes were separately performed and then compared with VCTE. Liver elasticity cutoffs for different stages of fibrosis were estimated in 3 ways: optimized sensitivity and specificity using the Youden index; and with sensitivity and specificity fixed at 90% each, Diagnostic accuracy for fibrosis was compared with liver histology using the area under the receiver-operating characteristic curve (AUROC). The primary outcome was the diagnostic accuracy of EUS-SWE for advanced fibrosis. Secondary outcomes were diagnostic accuracy of VCTE, EUS-SWE for left and right hepatic lobes for significant/advanced fibrosis, and cirrhosis. RESULTS: Forty-two patients (39 men, aged 54.5 ± 12.1 years) underwent EUS-SWE, VCTE, and liver biopsy sampling. The cross-validated AUROCs for advanced fibrosis were as follows: VCTE, .87 (95% confidence interval [CI], .76-.97); EUS-SWE left lobe, .8 (95% CI, .64-.96); and EUS-SWE right lobe, .78 (95% CI, .62-.95). The corresponding AUROCs for cirrhosis were as follows: VCTE, .9 (95% CI, .83-.97); EUS-SWE left lobe, .96 (95% CI, .9-1); and EUS-SWE right lobe, .9 (95% CI, .8-1). VCTE was unreliable in 8 patients who successfully underwent EUS-SWE. There was no statistically significant difference in the AUROCs for EUS-SWE and VCTE. CONCLUSIONS: EUS-SWE correlates well with liver histology and is a safe and reliable diagnostic test for assessing liver fibrosis with accuracy comparable with VCTE. (Clinical trial registration number: NCT04533932.).
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Técnicas de Imagem por Elasticidade , Cirrose Hepática , Humanos , Masculino , Técnicas de Imagem por Elasticidade/efeitos adversos , Cirrose Hepática/diagnóstico por imagem , Projetos Piloto , Estudos Prospectivos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Reprodutibilidade dos TestesRESUMO
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of post-transplant strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent for extrahepatic strictures. In patients with unclear diagnoses or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be ensured.
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Colestase , Transplante de Fígado , Humanos , Estados Unidos , Constrição Patológica/etiologia , Constrição Patológica/terapia , Colangiopancreatografia Retrógrada Endoscópica , Transplante de Fígado/efeitos adversos , Colestase/etiologia , Colestase/cirurgia , Stents , Endoscopia GastrointestinalRESUMO
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.
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Colestase , Transplante de Fígado , Humanos , Constrição Patológica/etiologia , Constrição Patológica/terapia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Transplante de Fígado/efeitos adversos , Colestase/etiologia , Colestase/cirurgia , Stents , Endoscopia GastrointestinalRESUMO
BACKGROUND AND AIMS: Performing a high-quality colonoscopy is critical for optimizing the adenoma detection rate (ADR). Colonoscopy withdrawal time (a surrogate measure) of ≥6 minutes is recommended; however, a threshold of a high-quality withdrawal and its impact on ADR are not known. METHODS: We examined withdrawal time (excluding polyp resection and bowel cleaning time) of subjects undergoing screening and/or surveillance colonoscopy in a prospective, multicenter, randomized controlled trial. We examined the relationship of withdrawal time in 1-minute increments on ADR and reported odds ratio (OR) with 95% confidence intervals. Linear regression analysis was performed to assess the maximal inspection time threshold that impacts the ADR. RESULTS: A total of 1142 subjects (age, 62.3 ± 8.9 years; 80.5% men) underwent screening (45.9%) or surveillance (53.6%) colonoscopy. The screening group had a median withdrawal time of 9.0 minutes (interquartile range [IQR], 3.3) with an ADR of 49.6%, whereas the surveillance group had a median withdrawal time of 9.3 minutes (IQR, 4.3) with an ADR of 63.9%. ADR correspondingly increased for a withdrawal time of 6 minutes to 13 minutes, beyond which ADR did not increase (50.4% vs 76.6%, P < .01). For every 1-minute increase in withdrawal time, there was 6% higher odds of detecting an additional subject with an adenoma (OR, 1.06; 95% confidence interval, 1.02-1.10; P = .004). CONCLUSIONS: Results from this multicenter, randomized controlled trial underscore the importance of a high-quality examination and efforts required to achieve this with an incremental yield in ADR based on withdrawal time. (Clinical trial registration number: NCT03952611.).
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Adenoma , Pólipos do Colo , Neoplasias Colorretais , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Estudos Prospectivos , Neoplasias Colorretais/diagnóstico , Fatores de Tempo , Adenoma/diagnóstico , Colonoscopia/métodos , Detecção Precoce de Câncer , Pólipos do Colo/diagnósticoRESUMO
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI.
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Endoscopia Gastrointestinal , Ergonomia , Humanos , Postura , Fatores de RiscoRESUMO
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the diagnosis of malignancy in patients with biliary strictures of undetermined etiology. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the role of fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS in the diagnosis of malignancy in patients with biliary strictures. In the endoscopic workup of these patients, we suggest the use of fluoroscopic-guided biopsy sampling in addition to brush cytology over brush cytology alone, especially for hilar strictures. We suggest the use of cholangioscopic and EUS-guided biopsy sampling especially for patients who undergo nondiagnostic sampling, cholangioscopic biopsy sampling for nondistal strictures and EUS-guided biopsy sampling distal strictures or those with suspected spread to surrounding lymph nodes and other structures.
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Biliary strictures of undetermined etiology pose a diagnostic challenge for endoscopists. Despite advances in technology, diagnosing malignancy in biliary strictures often requires multiple procedures. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the available literature on strategies used to diagnose undetermined biliary strictures. Using a systematic review and meta-analysis of each diagnostic modality, including fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS-guided FNA or fine-needle biopsy sampling, the American Society for Gastrointestinal Endoscopy Standards of Practice Committee provides this guideline on modalities used to diagnose biliary strictures of undetermined etiology. This document summarizes the methods used in the GRADE analysis to make recommendations, whereas the accompanying article subtitled "Summary and Recommendations" contains a concise summary of our findings and final recommendations.
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This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches.
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Adenocarcinoma , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Neoplasias Gástricas , Humanos , Adenocarcinoma/cirurgia , Adenocarcinoma/patologia , Ressecção Endoscópica de Mucosa/métodos , Endoscopia Gastrointestinal/métodos , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/patologia , Estudos Retrospectivos , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/patologia , Resultado do TratamentoRESUMO
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based summary and recommendations regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. It is accompanied by the document subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well- or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, we suggest surgical evaluation over endoscopic approaches.
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Adenocarcinoma , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Neoplasias Gástricas , Humanos , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/patologia , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/patologia , Ressecção Endoscópica de Mucosa/métodos , Endoscopia Gastrointestinal , Adenocarcinoma/cirurgia , Adenocarcinoma/patologia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: A subset of patients needing long-term enteral access are unable to undergo a conventional transoral "pull" percutaneous endoscopic gastrostomy (PEG). We assessed the safety and efficacy of an introducer-style endoscopic direct PEG (DPEG) and an interventional radiologist guided gastrostomy (IRG) among patients unable to undergo a pull PEG. METHODS: In this single center, non-randomized, pilot study, patients unable to undergo a transoral Pull PEG were prospectively recruited for a DPEG during the index endoscopy. IRG procedures performed at our center served as the comparison group. The primary outcome was technical success and secondary outcomes included 30-day and 90-day all-cause mortality, procedure duration, dosage of medications, adverse events, and 30-day all-cause hospitalization. The Charlson comorbidity index was used to compare comorbidities. RESULTS: A total of 47 patients (68.3 ± 7.13 years) underwent DPEG and 45 patients (68.6 ± 8.23 years) underwent IRG. The respective Charlson comorbidity scores were 6.37 ± 2 and 6.16 ± 1.72 (P = 0.59). Malignancies of the upper aerodigestive tract were the most common indications for DPEG and IRG (42 vs. 37; P = 0.38). The outcomes for DPEG and IRG were as follows: technical success: 96 vs. 98%; P = 1; 30-day all-cause mortality: 0 vs 15%, P < 0.01; 90-day all-cause mortality: 0 vs. 31%, P < 0.001; 30-day hospitalization: 19 vs. 38%; P = 0.06; procedure duration: 23.8 ± 1.39 vs. 29.5 ± 2.03 min, P = 0.02; midazolam dose: 4.5 ± 1.6 vs. 1.23 ± 0.6 mg; P < 0.001, and opiate dose: 105.6 ± 38.2 vs. 70.7 ± 34.5 µg, P < 0.001, respectively. Perforation of the colon during IRG was the sole serious adverse event. CONCLUSION: DPEG is a safe and effective alternative to IRG in patients unable to undergo a conventional transoral pull PEG and may be considered as a primary modality for enteral support. CLINICALTRIALS: gov Identifier: NCT04151030.
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Gastrostomia , Estomas Cirúrgicos , Humanos , Gastrostomia/efeitos adversos , Gastrostomia/métodos , Projetos Piloto , Endoscopia Gastrointestinal/efeitos adversos , Radiografia , Estudos RetrospectivosRESUMO
Guidelines recommend that patients with mild gallstone pancreatitis (GSP) without necrosis or infection should undergo cholecystectomy during the index hospitalization before discharge.1,2 However, in routine clinical practice, cholecystectomy is often performed several weeks after hospital discharge, or not performed at all.3.
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Cálculos Biliares , Pancreatite , Colecistectomia , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Hospitalização , Humanos , Tempo de Internação , Pancreatite/diagnóstico , Pancreatite/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND & AIMS: The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group. METHODS: We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups. RESULTS: Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06-1.51; I2=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31-3.69; I2=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72-3.20; I2=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76-1.74; I2=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30-4.75; I2=38%) and no adenomas (OR, 2.69; 95% CI, 1.87-3.87; I2=0). CONCLUSIONS: The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.
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Adenoma/diagnóstico por imagem , Adenoma/patologia , Neoplasias Colorretais/epidemiologia , Colonoscopia , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/mortalidade , Humanos , Incidência , Fatores de RiscoRESUMO
BACKGROUND AND AIMS: Mucosal exposure devices including distal attachments such as the cuff and cap have shown variable results in improving adenoma detection rate (ADR) compared with high-definition white light colonoscopy (HDWLE). METHODS: We performed a prospective, multicenter randomized controlled trial in patients undergoing screening or surveillance colonoscopy comparing HDWLE to 2 different types of distal attachments: cuff (CF) (Endocuff Vision) or cap (CP) (Reveal). The primary outcome was ADR. Secondary outcomes included adenomas per colonoscopy, advanced adenoma and sessile serrated lesion detection rate, right-sided ADR, withdrawal time, and adverse events. Continuous variables were compared using Student's t test and categorical variables were compared using chi-square or Fisher's exact test using statistical software Stata version16. A P value <.05 was considered significant. RESULTS: A total of 1203 subjects were randomized to either HDWLE (n = 384; mean 62 years of age; 81.3% males), CF (n = 379; mean 62.7 years of age; 79.9% males) or CP (n = 379; mean age 62.1 years of age; 80.5% males). No significant differences were found among 3 groups for ADR (57.3%, 59.1%, and 55.7%; P = .6), adenomas per colonoscopy (1.4 ± 1.9, 1.6 ± 2.4, and 1.4 ± 2; P = .3), advanced adenoma (7.6%, 9.2%, and 8.2%; P = .7), sessile serrated lesion (6.8%, 6.3%, and 5.5%; P = .8), or right ADR (48.2%, 49.3%, and 46.2%; P = .7). The number of polyps per colonoscopy were significantly higher in the CF group compared with HDWLE and CP group (2.7 ± 3.4, 2.3 ± 2.5, and 2.2 ± 2.3; P = .013). In a multivariable model, after adjusting for age, sex, body mass index, withdrawal time, and Boston Bowel Preparation Scale score, there was no impact of device type on the primary outcome of ADR (P = .77). In screening patients, CF resulted in more neoplasms per colonoscopy (CF: 1.7 ± 2.6, HDWLE: 1.3 ± 1.7, and CP: 1.2 ± 1.8; P = .047) with a shorter withdrawal time. CONCLUSIONS: Results from this multicenter randomized controlled trial do not show any significant benefit of using either distal attachment devices (CF or CP) over HDWLE, at least in high-detector endoscopists. The Endocuff may have an advantage in the screening population. (ClinicalTrials.gov, Number: NCT03952611).
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Adenoma , Pólipos do Colo , Neoplasias Colorretais , Idoso , Idoso de 80 Anos ou mais , Colonoscopia , Detecção Precoce de Câncer , Feminino , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Informed consent is the cornerstone of the ethical practice of procedures and treatments in medicine. The purpose of this document from the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee is to provide an update on best practice of the informed consent process and other issues around informed consent and shared decision-making for endoscopic procedures. The principles of informed consent are based on longstanding legal doctrine. Several new concepts and clinical trials addressing the best practice of informed consent will help guide practitioners of the burgeoning field of GI endoscopic procedures. After a literature review and an iterative discussion and voting process by the ASGE Standards of Practice Committee, this document was produced to update our guidance on informed consent for the practicing endoscopist. Because this document was designed by considering the laws and broad practice of endoscopy in the United States, legal requirements may differ by state and region, and it is the responsibility of the endoscopist, practice managers, and other healthcare organizations to be aware of local laws. Our recommendations are designed to improve the informed consent experience for both physicians and patients as they work together to diagnose and treat GI diseases with endoscopy.
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Gastroenteropatias , Consentimento Livre e Esclarecido , Endoscopia Gastrointestinal , Gastroenteropatias/diagnóstico , Humanos , Estados UnidosRESUMO
BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition causing recurrent dysphagia and may predispose patients to repeated hospitalizations. We assessed temporal trends and factors affecting readmissions in patients with EoE. METHODS: Patients with primary diagnosis of EoE and/or a complication (dysphagia, weight loss, and esophageal perforation) from EoE between 2010 and 2017 were identified from the National Readmissions Database using the International Classification of Diseases codes. The primary outcome was incidence of EoE related 30-day readmission. Independent risk factors for readmissions were evaluated using multivariable logistic regression analysis. Secondary outcomes were temporal trends of readmissions and healthcare costs. RESULTS: Of the 2,676 (mean age 45 ± 17.8 years, 1,667 males) index adult admissions, 2,103 (79%) patients underwent an upper endoscopy during the admission. The mean length of stay (LOS) was 3 ± 3.7 days. The 30-day readmission rate was steady at 6.8% from 2010 to 2017 and majority of the readmissions occurred by day 10 of index discharge. Age > 70 years was associated with a higher trend in 30-day readmission (P < 0.001). Longer LOS, history of smoking and the presence of eosinophilic gastroenteritis predicted readmission. Conversely, a history of foreign body impaction and upper endoscopy (including esophageal dilation) at index admission were negatively associated with readmission. Mean hospital charges significantly increased from $24,783 in 2010 to $40,922 in 2017. CONCLUSION: Readmissions due to EoE are more likely to occur in the first 10 days of discharge and at a lesser rate when upper endoscopies are performed at the index admission.
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Esofagite Eosinofílica , Gastrite , Readmissão do Paciente/tendências , Adulto , Idoso , Esofagite Eosinofílica/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: A gastrostomy is generally performed in patients who are unable to maintain volitional intake of food. We compared outcomes of percutaneous endoscopic gastrostomy (PEG) and interventional radiologist-guided gastrostomy (IRG) using an integrated nationwide database. METHODS: Using the VA Informatics and Computing Infrastructure database, patients who underwent PEG or IRG from 2011 through 2021 were selected using Current Procedural Terminology and International Classification of Diseases codes. The primary outcome was the comparative incidence of adverse events between PEG and IRG. Secondary outcomes included all-cause mortality. Comorbidities were identified using International Classification of Diseases codes, and adjusted odds ratio (OR) for adverse events were calculated using multivariate logistic regression analysis. RESULTS: A total of 23,566 (70.7 ± 10.2 years) patients underwent PEG and 9,715 (69.6 ± 9.7 years) underwent IRG. Selected frequent indications for PEG vs IRG were as follows: stroke, 6.8% vs 5.3%, P < 0.01; aspiration pneumonia, 10.9% vs 6.8%, P < 0.001; feeding difficulties, 9.8% vs 6.3%, P < 0.01; and upper aerodigestive tract malignancies 58.8% vs 79.8%, P < 0.01. Across all subtypes of malignancies of the head and neck and foregut, the proportion of patients undergoing IRG was greater than those undergoing PEG (P < 0.001). The all-cause 30-day mortality and overall incidence of adverse events were significantly lower for PEG compared with those for IRG (PEG vs IRG): all-cause 30-day mortality, 9.35% vs 10.3% (OR 0.80; 95% confidence interval [CI] 0.74-0.87; P < 0.01); perforation of the colon, 0.12% vs 0.24% (OR 0.50; 95% CI 0.29-0.86; P = 0.04); peritonitis, 1.9% vs 2.7% (OR 0.68; 95% CI 0.58-0.79; P < 0.01); and hemorrhage 1.6% vs 1% (OR 1.47; 95% CI 1.18-1.83; P < 0.01). DISCUSSION: In a large nationwide database of more than 33,000 gastrostomy procedures, PEG was associated with a lower incidence of adverse outcomes and the 30-day mortality than IRG.
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Nutrição Enteral/métodos , Gastroscopia/métodos , Gastrostomia/métodos , Radiografia Abdominal/métodos , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos , Idoso , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Estados UnidosRESUMO
BACKGROUND AND AIMS: A gastrostomy tube is often required for inpatients requiring long-term nutritional access. We compared the safety and outcomes of 3 techniques for performing a gastrostomy: percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy by an interventional radiologist (IR-gastrostomy), and open gastrostomy performed by a surgeon (surgical gastrostomy). METHODS: Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a gastrostomy from 2016 to 2017. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. The selected patients were divided into 3 cohorts: PEG (0DH64UZ), IR-gastrostomy (0DH63UZ), and open surgical gastrostomy (0DH60UZ). Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis. RESULTS: Of the 184,068 patients meeting the selection criteria, the route of gastrostomy tube placement was as follows: PEG, 16,384 (53.7 ± 29.0 years); IR-gastrostomy, 154,007 (67.2 ± 17.5 years); and surgical gastrostomy, 13,677 (57.9 ± 24.3 years). Compared with PEG, the odds for colon perforation using IR-gastrostomy and surgical gastrostomy, respectively, were 1.90 (95% confidence interval [CI], 1.26-2.86; P = .002) and 6.65 (95% CI, 4.38-10.12; P < .001), for infection of the gastrostomy 1.28 (95% CI, 1.07-1.53; P = .006) and 1.61 (95% CI, 1.29-2.01; P < .001), for hemorrhage requiring blood transfusion 1.84 (95% CI, 1.26-2.68; P = .002) and 1.09 (95% CI, .64-1.86; P = .746), for nonelective 30-day readmission 1.07 (95% CI, 1.03-1.12; P = .0023) and 1.13 (95% CI, 1.06-1.2; P = .0002), and for inpatient mortality 1.09 (95% CI, 1.02-1.17; P = .0114) and 1.55 (95% CI, 1.42-1.69; P < .0001). CONCLUSIONS: Placement of a gastrostomy tube (PEG) endoscopically is associated with a significantly lower risk of inpatient adverse events, mortality, and readmission rates compared with IR-gastrostomy and open surgical gastrostomy.
Assuntos
Gastrostomia , Pacientes Internados , Endoscopia , Nutrição Enteral , Gastrostomia/efeitos adversos , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND AND AIM: Biliary strictures are a common complication of liver transplantation. We assess the impact of post-transplant biliary strictures and describe the outcomes of endoscopic retrograde cholangiopancreatography (ERCP), interventional radiology (IR), and surgical therapies. METHODS: Using the Nationwide Readmissions Database (NRD), hospitalized liver transplant recipients were identified using the International Classification of Diseases 10th Revision codes. Patients with post-transplant biliary strictures were identified, and outcomes (inpatient mortality, 30-day readmission, transplant rejection/infection/failure, and disposition) were compared with transplant recipients without strictures. Among transplant patients with biliary strictures who underwent therapeutic intervention, corresponding outcomes were compared between IR, surgical interventions, and ERCP. RESULTS: Of the 8300 liver transplant recipients meeting selection criteria, 554 patients (age 48.9 ± 18.2 years, mean ± SD; 39.5% women) had biliary strictures. Compared with patients without strictures, the adjusted odds ratio (OR) for various outcomes in patients with biliary strictures were as follows: 1.46 (1.20, 1.77; P < 0.001) for 30-day non-elective readmission, 2.71 (2.04, 3.59; P < 0.001) allograft rejection, 2.32 (1.61, 3.37; P < 0.001) liver transplant failure, 3.05 (1.39, 6.73; P < 0.01) infection, and 1.41 (1.08, 1.82; P = 0.01) disposition to skilled nursing or intermediate care facility. Therapeutic interventions during index hospitalization were performed in 350 patients: ERCP 46.6% (n = 163), surgery 41% (n = 144), and IR 12.3% (n = 43) patients. Compared with ERCP, the adjusted odds for various outcomes were disposition to skilled nursing or intermediate care facility 2.72 (1.08, 6.87; P = 0.03) and 2.09 (1.05, 4.15; P = 0.036), prolongation of hospitalization 14.4 (3.7, 25.1; P = 0.008) and 15.0 (7.4, 22.7; P < 0.001), and failure of liver allograft 8.47 (1.47, 48.6; P = 0.017) and 12.23 (2.74, 54.4; P = 0.001) for IR and surgical interventions, respectively. CONCLUSION: Post-liver transplant biliary strictures are associated with increased rates of allograft rejection, allograft failure/infections, and readmissions. Compared with ERCP, management of these patients with IR or surgical interventions is associated with significantly higher rates of allograft failure and hospital stay.