ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Transgastric endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with esophageal narrowing using the ultrasonic bronchovideoscope.

Endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) is emerging as a critical technology in the evaluation of mediastinal lesions and is increasingly regarded as complementary to endoscopic ultrasound (EUS) in this arena. This complementary role may extend into the abdomen in cases where esophageal strictures prevent the passage of the echoendoscope. The objective of the study was to characterize the uses of EBUS-FNA in the evaluation of gastrointestinal lesions in patients with esophageal narrowing. The study design was a single-center case series. The setting was in a tertiary referral center. Four patients underwent EBUS-FNA to evaluate gastrointestinal lesions; esophageal strictures prevented EUS passage in three, the fourth patient did not tolerate transbronchial EBUS but had abdominal lesions within reach of the EBUS scope. EBUS was used to evaluate the liver, adrenal gland, a retroperitoneal mass, and a celiac axis lymph node. EBUS-FNA has greater potential to evaluate abdominal lesions than has been previously recognized. The EBUS scope represents a safe and readily available technology to evaluate patients with esophageal strictures. Interventional endoscopists should be exposed to this modality.

Endoscopic evaluation and treatment of esophageal cance.

Esophageal cancer is the sixth leading cause of cancer mortality. During the past twenty years the prevalence of adenocarcinoma, which is linked to gastroesophageal reflux and Barrett's metaplasia, has increased precipitously for unclear reasons. Endoscopic ultrasound (EUS) has revolutionized primary tumor (T) and nodal (N) staging. Additionally, the recent introduction of combined computed and positron emission tomography (CT-PET) promises to improve the detection of distant metastasis. While classic surgical approaches have significant morbidity and mortality, the recent widespread introduction of minimally invasive techniques including endoscopic mucosal resection and radiofrequency ablation offer new options to those with limited disease. Finally, endoscopically placed self expandable metal stents have become the primary mode of palliating dysphagia and there is a growing interest in the use of removable stents to optimize nutrition in neoadjuvant chemotherapy patients awaiting esophagectomy. In this article we will review the presentation, staging, and treatment of esophageal cancer with an emphasis on the evolving role of endoscopy to help accomplish these objectives.

Combined spinal-epidural for labor analgesia.

Since the introduction of the combined spinal-epidural technique in the early 1980s it has gained increasing popularity for analgesia and anesthesia in labor and delivery. The benefit of the rapid onset of analgesia from the intrathecal injection, coupled with the flexibility of an epidural catheter that can provide a long duration of labor analgesia or conversion to an anesthetic when operative delivery is necessary, has made combined spinal-epidural the labor analgesic of choice in many obstetric anesthesia practices.

Intraoperative air embolism with pulse irrigation device.

Venous air embolism is a potentially fatal complication. In a patient undergoing extensive debridement of an open perineal wound, hemodynamically significant air embolization occurred during use of a pulsatile saline irrigation device. We describe another intraoperative setting in which venous air embolism is a risk.

Perianesthetic considerations for the elderly patient.

The principles that guide the perianesthetic management of the elderly patient are the same as those used for all patients. What makes the care of this group challenging is not learning a new set of principles, but rather understanding the specific application of these guidelines to the unique traits of elderly patients. Only then is it possible to avoid complications that the elderly patient has very little margin of reserve to deal with.