When to feed after percutaneous endoscopic gastrostomy: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Initiation of feeding after percutaneous endoscopic gastrostomy (PEG) placement has been debated. Randomized controlled trials (RCTs) have been performed on early feeding compared with delayed feeding after PEG placement with varying results. Therefore, a meta-analysis was conducted examining early vs delayed feeding after placement of a PEG. METHODS: A comprehensive search of databases was conducted in January 2024. Peer-reviewed published RCTs comparing early feeding (≤4 h) with delayed feeding (>4 h) were identified and included in the meta-analysis. Meta-analysis was completed using pooled estimates of overall complications, individual complications, mortality ≤72 h, and number of day 1 significant gastric residual volumes. RESULTS: Six RCTs (n = 467) were included in the analysis. Comparison of early feeding with delayed feeding after PEG showed no statistically significant differences for overall complications (P = 0.18), mortality ≤72 h (P = 0.3), and number of day 1 significant gastric residual volumes (P = 0.05). No differences were also noted for individual complications, including vomiting, wound infection, bleeding, or diarrhea. CONCLUSION: Feeding ≤4 h after PEG have no differences in minor and major complications compared with that of delayed feeding. Early feeding ≤4 h is safe and should be recommended in future guidelines.

Interprofessional implementation of the Global Malnutrition Composite Score quality measure.

Malnutrition in hospitalized patients can impact health outcomes, quality of life, and health equity. Quality improvement initiatives and quality measurement can help improve the care of those hospitalized patients with malnutrition. The new Global Malnutrition Composite Score (GMCS) was recently adopted by the Centers for Medicare & Medicaid Services (CMS) as a health equity-focused measure. Beginning in 2024, the GMCS is available for reporting through the CMS Hospital Inpatient Quality Reporting Program. The GMCS provides an opportunity to elevate the importance of patient nutrition status and evidence-based interventions throughout the interdisciplinary hospital decision-making process. To promote this opportunity, the American Society for Parenteral and Enteral Nutrition (ASPEN) held an "Interprofessional implementation of the Global Malnutrition Composite Score" webinar as part of its 2022 Malnutrition Awareness Week programming. This article summarizes the underlying rationale and significance of the GMCS measure and showcases clinical observations about integrating quality improvement and measurement into the acute care setting, as presented during the webinar.

When is enteral nutrition indicated?

Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.

EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review.

Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis. Methods: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights.  Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68-74). Bias calculated using Begg-Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61-71) and 57% (95% CI = 48-67), respectively. Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis.

BACKGROUND: Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed. METHODS: An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted. RESULTS: The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs. CONCLUSION: Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Systematic Review and Meta-Analysis: Preoperative Vedolizumab and Postoperative Complications in Patients with IBD.

OBJECTIVES: The effect of vedolizumab on postoperative outcomes in patients with inflammatory bowel disease (IBD) remains unclear. We aimed to determine the relation between preoperative vedolizumab and early postoperative complications in patients with IBD undergoing abdominal surgery. METHODS: A search of databases and abstracts from gastroenterology conferences was performed. Primary outcomes included overall and infectious postoperative complication rates as well as surgical site infections. Studies that compared Crohn disease, ulcerative colitis, or patients with IBD-undefined with preoperative vedolizumab treatment undergoing abdominal surgery with controls with preoperative antitumor necrosis factor-α (anti-TNF-α) treatment or no preoperative biologic treatment were included. A meta-analysis was completed using the Mantel-Haenszel and DerSimonian and Laird models. RESULTS: Six studies totaling 1201 patients were included; 281 patients were treated preoperatively with vedolizumab, 327 patients were treated preoperatively with anti-TNF-α agents, and 593 patients were not treated preoperatively with any biologics. There was no significant difference in overall complications (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.48-2.24, P = 0.92, I2 =77%) between the vedolizumab and no-biologic groups. There also was no significant difference in infectious complications (OR 1.00, 95% CI 0.37-2.69, P = 1.00, I2 = 78%), which persisted after sensitivity analysis (OR 0.71, 95% CI 0.31-1.60, P = 0.41, I2 = 46%). Furthermore, there was no significant difference in overall complications (OR 0.77, 95% CI 0.24-2.46, P = 0.66, I2 = 85%) and infectious complications (OR 0.89, 95% CI 0.20-3.94, P = 0.87, I2 = 86%) between the vedolizumab and anti-TNF-α groups. After sensitivity analysis, differences in overall and infectious complications remained insignificant (OR 0.54 and 0.50, 95% CI 0.24-1.17 and 0.22-1.15, P = 0.12 and 0.10, I2 = 39% and 18%, respectively). Vedolizumab was also not associated with a significant increase in surgical site infections compared with the no-biologic (OR 1.45, 95% CI 0.33-6.32, P = 0.62, I2 = 75%) and anti-TNF (OR 1.30, 95% CI 0.22-7.60, P = 0.77, I2 = 81%) groups. CONCLUSIONS: Preoperative treatment with vedolizumab in patients with IBD undergoing abdominal surgery is not associated with increases in overall or infectious postoperative complications compared with preoperative anti-TNF-α treatment and no preoperative biologic treatment. Large, prospective studies are needed to further assess the impact of preoperative vedolizumab treatment on postoperative complications, particularly with respect to IBD subtype.

Should I Start With A Postpyloric Enteral Nutrition Modality?

Nutrition therapy is a key element in the management of malnourished and critically ill patients. Although many aspects of enteral nutrition (EN) have been well defined by research, with clear recommendations by 3 major society guidelines, EN delivery method remains a topic for debate. The goal of this manuscript is to concisely review gastric vs postpyloric enteral feeding in critically ill adult patients and provide a set of recommendations to individualize EN delivery method based on patient characteristics and specific needs.

Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients.

OBJECTIVE: The preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) in inflammatory bowel disease (IBD) patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. We aimed to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery. METHODS: A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and noninfectious postoperative complications. RESULTS: Forty-one studies totaling 20 274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs. controls [odds ratio (OR) = 1.13, 95% confidence interval (CI), 1.01-1.25, P = 0.03, I2 = 6%] with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR = 1.44; 95% CI 1.02-2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR = 1.44, 95% CI 1.13-1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR = 1.57, 95% CI 1.15-2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only. CONCLUSION: Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients.

Endoscopic ultrasound-guided fiducial marker placement in pancreatic cancer: A systematic review and meta-analysis.

BACKGROUND: Pancreatic cancer (PC) mortality remains high despite advances in therapy. Combination chemoradiotherapy offers modest survival benefit over monotherapy with either. Fiducial markers serve as needed landmarks for image-guided radiotherapy (IGRT). Traditionally, these markers were placed surgically or percutaneously with limitations of each. Endoscopic ultrasound-guided placement overcomes these limitations. AIM: To evaluate the safety, efficacy, and feasibility of endoscopic ultrasound (EUS)-guided fiducial placement for PC undergoing IGRT. METHODS: Articles were searched in MEDLINE, PubMed, and Ovid journals. Pooling was conducted by fixed and random effects models. Heterogeneity was assessed using Cochran's Q test based upon inverse variance weights. RESULTS: Initial search identified 1024 reference articles for EUS-guided fiducial placement in PC. Of these, 261 relevant articles were reviewed. Data was extracted from 11 studies (n = 820) meeting inclusion criteria. Pooled proportion of successful placement was 96.27% (95%CI: 95.35-97.81) with fiducial migration rates low at 4.33% (95%CI: 2.45-6.71). Adverse event rates remained low, with overall pooled proportion of 4.85% (95%CI: 3.04-7.03). CONCLUSION: EUS-guided placement of fiducial markers for IGRT of PC is safe, feasible, and efficacious. The ability to target deep structures under direct visualization while remaining minimally invasive are added benefits. Moreover, the ability to perform fine needle aspiration or celiac plexus neurolysis add value and increase patient-care efficiency. Whether EUS-guided fiducial placement improves outcomes in IGRT or offers any mortality benefits over traditional placement remains unknown and future studies are needed.

Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States.

OBJECTIVE: Healthcare leaders seek guidance on prudent investment in programs that improve patient outcomes and reduce costs, which includes the value of nutrition therapy. The purpose of this project was to conduct an evidence review and evaluate claims analyses to understand the financial and quality impact of nutrition support therapy on high-priority therapeutic conditions. METHODS: Task 1 included a review of existing literature from 2013 to 2018 to identify evidence that demonstrated the clinical and economic impact of nutrition intervention on patient outcomes across 13 therapeutic areas (TAs). In Task 2, analytic claims modeling was performed using the Medicare Parts A and B claims 5% sample dataset. Beneficiaries diagnosed in 5 selected TAs (sepsis, gastrointestinal [GI] cancer, hospital-acquired infections, surgical complications, and pancreatitis) were identified in the studies from Task 1, and their care costs were modeled based on nutrition intervention. RESULTS: Beginning with 1099 identified articles, 43 articles met the criteria, with a final 8 articles used for the Medicare claims modeling. As examples of the modeling demonstrated, the use of advanced enteral nutrition formula could save at least $52 million annually in a sepsis population. The total projected annual cost savings from the 5 TAs was $580 million. CONCLUSION: Overall, optimization of nutrition support therapy for specific patient populations is estimated to reduce Medicare spending by millions of dollars per year across key TAs. These findings demonstrate the evidence-based value proposition of timely nutrition support to improve clinical outcomes and yield substantial cost savings.

Dispelling Myths and Unfounded Practices About Enteral Nutrition.

Many protocols and steps in the process of enteral nutrition (EN) use are not overly supported with strong research and have been done the same way over many years without questioning the use of best-practices evidence. This article reports many of the myths and unfounded practices surrounding EN and attempts to refute those myths with current evidence. These practices include those about enteral access devices, formulas, enteral administration, and complications.

Impact of moderate versus deep sedation on adenoma detection rate in index average-risk screening colonoscopies.

BACKGROUND AND AIMS: The debate between moderate sedation versus deep sedation for index average-risk screening colonoscopies is well known to gastroenterologists. Ensuring the best of all metrics to perform quality colonoscopies for colon cancer prevention is paramount for both patients and physicians alike, because colon cancer remains the leading cause of cancer death and is the most-used screening tool in the United States. The aim of this study was to determine if moderate sedation versus deep sedation affects outcomes of adenoma detection rate (ADR) or polyp detection rate (PDR) in index, average-risk colonoscopies for colon cancer screening. METHODS: A retrospective, single, tertiary care outpatient center study of 585 healthy average-risk patients who underwent index screening colonoscopy between June 1, 2015 to December 31, 2015 (moderate sedation only) and June 1, 2016,to December 31, 2016 (deep sedation only) was performed after Institutional Review Board approval. Demographic data and polyp details were collected to determine ADR and PDR. Patients who were not average risk were excluded from the study. RESULTS: A total of 585 index average-risk screening colonoscopies were included in this study with 57.7% moderate sedation and 42.2% deep sedation. Neither ADR nor PDR was significantly different between the 2 groups (44.1% vs 38.5% [P = .18] and 71.9% vs 67.6% [P = .27], respectively). CONCLUSIONS: In index average-risk screening colonoscopies, deep sedation appears to have no benefit compared with moderate sedation for ADR and PDR.

Peroral cholangioscopy with cholangioscopy-directed biopsies in the diagnosis of biliary malignancies: a systemic review and meta-analysis.

BACKGROUND AND AIM: Accurate diagnosis is essential in the appropriate management of biliary strictures. Our aim is to evaluate the efficacy of cholangioscopy-directed biopsies in differentiating biliary intraductal malignancies from benign lesions. MATERIALS AND METHODS: Articles were searched in Medline, PubMed, and Ovid journals. Pooling was performed by both fixed-effects and random-effects models. Only studies from which a 2×2 table could be constructed for true-positive, false-negative, false-positive, and true-negative values were included. RESULTS: Initial search identified 2110 reference articles for peroral cholangioscopy; of these, 160 relevant articles were selected and reviewed. Data were extracted from 15 studies (N=539) that fulfilled the inclusion criteria. Pooled sensitivity of cholangioscopy-directed biopsies in diagnosing malignancy was 71.9% [95% confidence interval (CI): 66.1-77.1] and pooled specificity was 99.1% (95% CI: 96.9-99.9). The positive likelihood ratio of cholangioscopy-directed biopsies was 18.1 (95% CI: 9.1-35.8), whereas the negative likelihood ratio was 0.3 (95% CI: 0.2-0.4). The pooled diagnostic odds ratio was 71.6 (95% CI: 32.8-156.4). All the pooled estimates calculated by fixed-effects and random-effect models were similar. Summary receiver operating characteristic curves showed an area under the curve of 0.98. The χ heterogeneity for all the pooled accuracy estimates was 5.62 (P=0.96). CONCLUSION: Peroral cholangioscopy with cholangioscopy-directed biopsies has a high specificity in differentiating intraductal malignancies from benign lesions. Cholangioscopy-directed biopsies should be strongly considered for biliary stricture evaluation.

Efficacy and Safety of Lumen Apposing Self-Expandable Metal Stents for EUS Guided Cholecystostomy: A Meta-Analysis and Systematic Review.

Background: Patients with acute cholecystitis are treated with early cholecystectomy. A subset of patients are unfit for surgery due to comorbidities and late presentation. Prompt gall bladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for nonoperative candidates. Endoscopic ultrasound (EUS) guided transluminal gall bladder drainage (EUS-GBD) continues to evolve as an alternative approach to percutaneous drainage. With continued refinement in stent technology, lumen apposing self-expandable metal stent (LAMS) offers several advantages. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in nonoperative candidates with acute cholecystitis. Methods: Extensive English language literature search was performed in Medline, Embase, Cochrane Central, and Google Scholar using keywords "endoscopic ultrasound", "stent", "gallbladder", "acute cholecystitis", and "cholecystostomy" from Jan 2000 to Dec 2016. Fixed and random effects models were used to calculate the pooled proportions. Results: Data was extracted from 13 studies that met the inclusion criteria (n = 233). Pooled proportion of technical success was 93.86% (95% CI = 90.56 to 96.49) and clinical success was 92.48% (95% CI = 88.9 to 95.42). Overall complication rate was 18.31% (95% CI = 13.49 to 23.68) and stent related complication rate was 8.16% (95% CI = 4.03 to 14.96) in the pooled percentage of patients. Pooled proportion for perforation was 6.71% (95% CI 3.65 to 10.6) and recurrent cholangitis/cholecystitis was noted in 4.05% (95% CI = 1.64 to 7.48). Publication bias calculated using Harbord-Egger bias indicator gave a value of -0.61 (95% CI = -1.39 to 0.16, p = 0.11). The Begg-Mazumdar indicator for bias gave Kendall's tau b value of -0.42 (p ≥ 0.05). Conclusions: EUS-GBD with LAMS is a safe and alternative treatment modality for patients needing gallbladder drainage, with acceptable intraprocedural and postprocedural complications. However, due to the limited data and lack of direct comparison with other methods, further controlled trials are necessary to estimate the overall efficacy and safety and the role of EUS-GBD with LAMS in management of nonoperative patients with acute cholecystitis.

Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis.

OBJECTIVES: Crohn's disease (CD) patients frequently develop complications that require surgery for management. The high prevalence of malnutrition in CD patients presents a challenge because poor preoperative nutritional status has been shown to increase postoperative complications. In this study, we assessed whether preoperative enteral nutrition (EN) or total parenteral nutrition (TPN) decreases postoperative complications in CD patients. MATERIALS AND METHODS: A three-point systematic and comprehensive literature search was carried out on multiple databases followed by a meta-analysis with results presented as odds ratio (OR) using two models, the Mantel-Haenszel model and the DerSimonian and Laird model. The I measure of inconsistency was utilized to assess heterogeneity. If statistically significant heterogeneity was identified, the results underwent a separate sensitivity analysis. RESULTS: Five studies met inclusion criteria totaling 1111 CD patients. The rate of postoperative complications in the group receiving preoperative nutrition (EN or TPN) support was 20.0% compared with 61.3% in the group who had standard care without nutrition support [OR=0.26, 95% confidence interval (CI): 0.07-0.99, P<0.001]. Postoperative complications occurred in 15.0% of patients in the group who received preoperative TPN compared with 24.4% in the group who did not (OR=0.65, 95% CI: 0.23-1.88, P=0.43). Postoperative complications occurred in 21.9% in the group who received preoperative EN compared with 73.2% in the group that did not received preoperative EN (OR=0.09, 95% CI: 0.06-0.13, P<0.001). CONCLUSION: Preoperative nutrition supplementation reduces postoperative complications in CD patients. In particular, EN in CD patients before undergoing surgery is superior to standard of care without nutrition support with a number needed to treat of 2. There is a trend toward TPN being superior to standard of care without nutrition support, but this trend did not reach statistical significance. Further studies are necessary to evaluate specific components in EN or TPN that may be most beneficial for CD patients requiring surgical intervention.

Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials.

BACKGROUND: In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results. METHODS: Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models. RESULTS: Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively). CONCLUSIONS: The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

ASA Classification Pre-Endoscopic Procedures: A Retrospective Analysis on the Accuracy of Gastroenterologists.

OBJECTIVES: Before an endoscopic procedure, an evaluation to assess the risk of sedation is performed by the gastroenterologist. To risk stratify based on medical problems, the American Society of Anesthesiologists (ASA) classification scores are used routinely in the preprocedure evaluation. The objective of our study was to evaluate among physicians the ASA score accuracy pre-endoscopic procedures. METHODS: At a single tertiary-care center an institutional review board-approved retrospective study was performed. Upper endoscopies performed from May 2012 through August 2013 were reviewed; data were collected and recorded. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement (≤0.20 is poor agreement, 0.21-0.40 is fair, 0.41-0.60 is moderate, 0.61-0.80 is good, and 0.81-1.00 is very good). RESULTS: The mean ASA scores by the gastroenterologist compared with the anesthesiologist were 2.28 ± 0.56 and 2.78 ± 0.60, respectively, with only fair agreement (weighted kappa index 0.223, 95% confidence interval [CI] 0.113-0.333; 48% agreement). The mean ASA scores for gastroenterologists compared with other gastroenterologists were 2.26 ± 0.5 and 2.26 ± 0.44, respectively, with poor agreement (weighted kappa index 0.200, 95% CI 0.108-0.389; 68% agreement). Agreement on ASA scores was only moderate between the gastroenterologist and himself or herself (weighted kappa index 0.464, 95% CI 0.183-0.745; 75% agreement). CONCLUSIONS: Gastroenterologists performing preprocedure assessments of ASA scores have fair agreement with anesthesiologists, poor agreement with other gastroenterologists, and only moderate agreement with themselves. Given this level of inaccuracy, it appears that the ASA score pre-endoscopy is of limited significance.