Elective Endoscopy Research Articles

Noninvasive Colorectal Cancer Screening Tests Help Close Screening Gaps During Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has upended routine preventive care across the country. Health systems worldwide have seen a drastic decrease in utilization of preventive care services, including colorectal cancer (CRC) screening.1 In response to the pandemic, the US Surgeon General advised in March 2020 that all hospitals and ambulatory surgical centers delay nonurgent surgeries and medical procedures, including screening and surveillance colonoscopies. In line with these recommendations, the University of California Los Angeles (UCLA) health system temporarily ceased elective endoscopies and purposefully encouraged the use of stool-based CRC screening modalities among patients and providers through weekly system-wide e-mails to primary care and gastroenterology providers, virtual meetings with primary care leadership, and standardized educational materials for fecal immunochemical testing (FIT).

P38 COVID-19 impact on Surgical Training And Recovery Planning (COVID-STAR) Survey

BackgroundThe COVID-19 pandemic has resulted in dynamic changes to healthcare delivery. Surgery as a specialty has been significantly affected and with that the delivery of surgical training.MethodThis national, collaborative, cross sectional study comprising 13 surgical trainee associations distributed a pan surgical specialty survey on the COVID-19 impact on surgical training over a 4-week period (11th May - 8th June 2020). The survey was voluntary and open to medical students and surgical trainees of all specialties and training grades. All aspects of training were qualitatively assessed. This study was reported according to STROBE guidelines.Results810 completed responses were analysed. (M401: F 390) with representation from all deaneries and training grades. 41% of respondents (n = 301) were redeployed with 74% (n = 223) redeployed > 4 weeks. Complete loss of training was reported in elective operating (69.5% n = 474), outpatient activity (67.3%, n = 457), Elective endoscopy (69.5% n = 246) with > 50% reduction in training time reported in emergency operating (48%, n = 326) and completion of work-based assessments (WBA) (46%, n = 309). 81% (n = 551) reported course cancellations and departmental and regional teaching programmes were cancelled without rescheduling in 58% and 60% of cases respectively. A perceived lack of Elective operative exposure and completions of WBA’s were the primary reported factor affecting potential training progression. Overall, > 50% of trainees (n = 377) felt they would not meet the competencies required for that training period.ConclusionThis study has demonstrated a perceived negative impact on numerous aspects of surgical training affecting all training specialties and grades.

Distribución de estadios de OLGA y OLGIM según edad y estado del Helicobacter pylori en un hospital público nivel III en Lima, Perú

Introduction. The operative link for gastritis assessment (OLGA) and the operative link on gastric intestinal metaplasia assessment (OLGIM) staging systems have been suggested to provide risk of assessment for gastric cancer. Objective. To evaluate the distribution of OLGA and OLGIM staging by age and Helicobacter pylori status. Material and methods. We studied 197 subjects undergoing elective upper gastrointestinal endoscopy. The presence of the H. pylori and histological changes were evaluated using the updated Sydney system. Stages III and IV of OLGA/OLGIM were considered high risk stages. Results. The H. pylori rate was 56.85% (112/197). High-risk OLGA/OLGIM cases were rare: 7/112 (6.5%) cases of OLGA in the H. pylori positive group and 6/85 (7%) in the H. pylori negative group; 5 (4.4%) cases of OLGIM in the H. pylori positive and 6 (7%) in the H. pylori negative. The proportion of advanced stages of OLGA and OLGIM increased with age (p < 0.001). High-risk OLGA was not found before age 40 regardless of the presence of H. pylori, but increased to 16.2%, 10.3%, 17.3% and 40.8% in subjects in the fourth, fifth, sixth and seventh decade of life respectively. The OLGIM high risk showed a similar trend: 0% before 40 years and up to 22.6% in people of 70 years. Conclusions. High-risk OLGA/OLGIM cases are infrequent before age 40 and increase significantly with age. No relation was found with the presence of the H. pylori. According to these protocols, only a fifth of the patients would strictly require endoscopic control.

Sars-CoV-2 Infection in Lung Transplant Patients - Single Center Experience in Portugal

IntroductionLung transplant (LT) patients are immunosuppressed and it is yet to be determined if immunosuppression plays a role in SARS-CoV-2 infection. Due to this lack of information about COVID-19 in solid transplant patients, case series are of utmost importance. We report two cases of LT patients with COVID-19 at our LT center.Case ReportWe report a 60-year-old man submitted to a bilateral LT due to COPD in January 2020. Immunosuppression: basiliximab as induction and prednisolone, mycophenolate mofetil and tacrolimus as maintenance therapy. He was discharged 47 days post-operatively. Six months after LT, as routine screening to an elective endoscopy for previously controlled Barret's esophagus, RT-PCR of naso-pharyngeal swabs detected SARS-CoV-2 RNA, assuming the diagnosis of COVID-19. He was hospitalized for monitoring despite being asymptomatic. Oxygen saturation was always higher than 97% at room air. Leukocyte was 5.730 × 10^9/L (lymphopenia 530 × 10^9/L), D-dimer 1913 ug/L, C-reactive protein (CRP) 51,1 mg/l, ferritin 163,7 ng/mL and lactate dehydrogenase (LDH) 370 units/L. CT-scan excluded thromboembolism and active infection. He remain asymptomatic and was discharged. The second case was a 54-year-old man submitted to a bilateral LT due to COPD in June 2020. Immunosuppression: basiliximab as induction and prednisolone, mycophenolate mofetil and tacrolimus as maintenance therapy. He was discharged 76 days post-operatively due to post-infection anastomosis stenosis. Three months after LT, as routine screening to a bronchofibroscopy for revaluation of stenosis, RT-PCR naso-pharyngeal swabs detected SARS-CoV-2 RNA, assuming the diagnosis of COVID-19. He revealed more dyspnea (mMRC 2) and cough than usual, with no other symptoms. Oxygen saturation was always higher than 96% at room air. Leukocyte 7.560 × 10^9/L, CRP 41,5 mg/l, LDH 566 units/L. He stayed at home in isolation with mild symptoms that improved in one week to his previous health status. Both patients had no travel history and no known contact with SARS-CoV2-2 infected patient.SummaryWe report 2 cases among a total of 174 LT patients in follow‐up at our center (1,1%), we underline that SARS-CoV-2 infection can present itself with mild or no symptoms in LT patients that theoretically are more vulnerable. Also we reinforce the importance of routine screening of these patients before any procedure.

A78 THE IMPACT OFGASTROINTESTINAL FOLLOW UP CARE ON HEALTHCARE UTILIZATION IN PATIENTS WITH ESINOPHILICESOPHAGITID (EOE).

Abstract Background EOE is an increasingly recognized gastrointestinal condition that causes significant morbidity ranging from dietary limitations to food impactions requiring emergency room visits. There are a variety of dietary, pharmacologic and endoscopic treatments available but most are more practically guided by a subspecialist familiar and experienced with the condition. There is a perception among some physicians that follow up is sporadic and may be related at least in part to patient compliance. Aims To assess the true rate of EOE patients follow up rate at Lodon Health Scince Center Methods We used a retrospective cohort of patients diagnosed with EoE between July 2011 and June 2014 who met the traditional diagnostic criteria. As part of a quality improvement initiative, local follow up over the ensuing 5–7 years was tracked. The impact of follow up on subsequent healthcare utilization was analyzed. Results 123 patients with biopsy confirmed EoE were analyzed. Follow up appointments were made for 114/123 (92%) patients. 55/123 (45%) had repeat elective endoscopy booked. Only 10/114 (8.7%) of initial appointments went unattended but 15/55 (27.2%) of the patients offered ongoing follow up failed to attend. There were no complications (ie. perforation or bleeding) attributable to any of the procedures. 5/123 (4%) patients required repeat emergency room endoscopy for food impaction. Two patients required this on multiple occasions. 4/5 patients requiring repeat emergency room endoscopy for food impaction had received some sort of follow up, although 4/5 of these had at least one missed appointment. 2/5 patients having emergency room endoscopy required overnight admission. There were no perforations in the cohort. Conclusions Patients with a confirmed diagnosis of EOE do have a risk of requiring subsequent emergency endoscopy for food impaction although it is not clear that scheduled follow up significantly reduces that risk. Contrary to the perception of some physicians, patients with EoE are very likely to attend their first follow up visit although the attrition rate for subsequent scheduled visits is not insignificant. Funding Agencies None

A84 THE IMPACT OF GASTROINTESTINAL FOLLOW UP CARE ON HEALTHCARE UTILIZATION IN PATIENTS WITH EOSINOPHILIC ESOPHAGITIS (EOE).

Abstract Background EoE is an increasingly recognized gastrointestinal condition that causes significant morbidity ranging from dietary limitations to food impactions requiring emergency room visits. There are a variety of dietary, pharmacologic and endoscopic treatments available but most are more practically guided by a subspecialist familiar and experienced with the condition. There is a perception among some physicians that follow up is sporadic and may be related at least in part to patient compliance Aims To assess patients with EoE utilization of health care in LHSC Methods We used a retrospective cohort of patients diagnosed with EoE between July 2011 and June 2014 who met the traditional diagnostic criteria. As part of a quality improvement initiative, local follow up over the ensuing 5–7 years was tracked. The impact of follow up on subsequent healthcare utilization was analyzed. Results 123 patients with biopsy confirmed EoE were analyzed. Follow up appointments were made for 114/123 (92%) patients. 55/123 (45%) had repeat elective endoscopy booked. Only 10/114 (8.7%) of initial appointments went unattended but 15/55 (27.2%) of the patients offered ongoing follow up failed to attend. There were no complications (ie. perforation or bleeding) attributable to any of the procedures. 5/123 (4%) patients required repeat emergency room endoscopy for food impaction. Two patients required this on multiple occasions. 4/5 patients requiring repeat emergency room endoscopy for food impaction had received some sort of follow up, although 4/5 of these had at least one missed appointment. 2/5 patients having emergency room endoscopy required overnight admission. There were no perforations in the cohort. Conclusions Patients with a confirmed diagnosis of EoE do have a risk of requiring subsequent emergency endoscopy for food impaction although it is not clear that scheduled follow up significantly reduces that risk. Contrary to the perception of some physicians, patients with EoE are very likely to attend their first follow up visit although the attrition rate for subsequent scheduled visits is not insignificant. Funding Agencies None

A146 EVALUATION OF A COLONOSCOPY REFERRAL FORM IN QUEBEC: WHICH INDICATIONS CARRIES A HIGHER RISK OF ADVANCED NEOPLASIA?

BackgroundPatients referral for colonoscopy in the province of Quebec are organized through a standardized triage sheet that includes all indications categorized in 5 hierarchal scheduling priorities. In the context of a restricted access to colonoscopy, exacerbated by the COVID-19 pandemic, postponed elective endoscopies lead to potential diagnostic and therapeutic delays in patients with colorectal neoplasia. There is currently an important need to evaluate available tools to improve patients prioritization.AimsThis study aims to determine CRC and advanced adenomas (AA) rates associated with indications of priority 3 (P3 fig.1). The secondary objective is to regroup and compare indications with higher and lower rate of CRC and AA.MethodsThis retrospective study included all adult patients who underwent a single diagnostic colonoscopy from March 2013 to March 2016 following a single FIT test in a tertiary teaching hospital. A literature review informed the adopted definition of higher-risk of CRC and AA according to P3 colonoscopy indications. These include: Positive FIT test (IN5), hematochezia in ≥ 40 years old patients (IN4), unexplained iron deficiency anemia (IN6) and symptoms suspicious of occult colorectal cancer (IN18). Lower risk P3 indications were defined as: suspicion of IBD (IN3), recent change in bowel habits (IN7), polyp viewed on imaging (IN17), inadequate bowel preparation (IN19), and diverticulitis follow-up (IN20). Higher and lower risk indications findings were analyzed.ResultsIn our cohort of 2226 patients, indications for colonoscopy referral according to the standardized form were available for 1806 patients (10 P1, 69 P2, 1056 P3, 56 P4 and 615 P5). In our studied group of P3 indications, the mean age was 62.6±11.3 years, 54.1% were female and 173 (16.4%) patients had a significant finding of CRC or AA (table 1). Patients referred for higher risk indications had a significantly increased rate of CRC and AA (19.3% vs 5.1% p≤ 0.01) compared to patients referred for lower risk indications.ConclusionsA standardized colonoscopy referral tool may be adapted to improve prioritization of patients at risk of advanced neoplasia. These findings are especially relevant in the context of limited access to colonoscopy like during a pandemic.Table 1. Detection rate of neoplastic findings for P3 indications(%) Higher-risk indications Lower-risk indications IN4 (N=230)IN5 (N=453)IN6 (N=156)IN18 (N=3)IN3 (N=41)IN7 (N=135)IN17 (N=5)IN20 (N=33) Non-advanced adenomas (NAA)47(20.4)192(42.6)41(26.5)1(33)5(12.2)25(18.5)4(80)6(18.2) Advanced adenomas (AA)21(9.2)116(25.7)8(5.2)01(2.4)8(5.9)01(3) Serrated polyps 11(4.8)42(9.4)5(3.2)006(4.5)01(3) Carcinoma (CRC)5(2.2)7(1.6)6(3.9)001(0.7)00 AA and CRC 26(11.3)123(27.2)14(9.0)01(2.4)9(6.6)01(3)Figure 1: Provincial colonoscopy referral form in Quebec (AH-702)Funding AgenciesNone

LMA® Gastro™: A paediatric experience

The laryngeal mask airway, the LMA® Gastro™ (Teleflex Medical, Athlone, Ireland), is a novel airway device which permits upper gastrointestinal (GI) endoscopy to be performed via a dedicated large calibre oesophageal lumen. It has been validated in adult studies, but to our knowledge, there have been no data published regarding its use in a paediatric population. Following a brief education programme, the LMA Gastro was introduced on a trial basis at our institution and made freely available. Over a four-month period, our pre-existing endoscopy audit framework captured data on a total of 55 patients who had the LMA Gastro device chosen as the primary airway for elective upper GI endoscopy. These data were collected prospectively by the treating anaesthetist and included a range of airway and endoscopy outcomes. Of the 55 patients, the LMA Gastro provided an adequate airway in 52 (94.5%). Forty-six (88.5%) were sited on first attempt, and 50 (96.2%) insertions were rated 'easy' by the anaesthetist. Aside from three insertion failures, there were no airway events. The endoscopy success rate was 100% in the 52 patients who had an LMA Gastro airway successfully inserted. First-pass oesophageal access was achieved in 51 (98%) cases, and 100% of insertions were rated 'easy' by the gastroenterologist. Despite our relative inexperience with it, the device had a high success rate for airway maintenance and oesophageal access in our paediatric patient population. In our institution, the LMA Gastro provided a useful airway option in older children undergoing elective upper GI endoscopy.

COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR) - A cross-sectional observational study.

BackgroundThe COVID-19 pandemic has resulted in significant changes to healthcare systems which impact the delivery of surgical training. This study aimed to investigate the qualitative impact of COVID-19 on surgical training in the United Kingdom (UK) & Republic of Ireland (ROI)MethodsThis national, collaborative, cross-sectional study involving 13 surgical trainee associations distributed a pan-surgical specialty questionnaire on the impact of COVID-19 on surgical training over 4 weeks in May 2020. Various aspects of training were assessed.Results810 completed responses were analysed (males = 401, females = 390) from all deaneries and training grades. The perceived negative overall impact of the pandemic on surgical training experience was significant. (Weighted average = 8.66). 41% of respondents (n = 301) were redeployed with 74% redeployed for >4 weeks. Complete loss of training was reported in elective operating (69.5%), outpatient activity (67.3%) and endoscopy (69.5%). A reduction of >50% was reported in emergency operating (48%) and completion of work-based assessments (WBAs) (46%). 3.3% (n = 17) of respondents reported plans to leave medicine altogether. Cancellations in study leave and regional teaching programmes without rescheduling were reported in 72% and 60% of the cohort respectively. Elective operative exposure and WBAs completion were the primary reported factors affecting potential trainee progression. Only 9% of trainees reported that they would definitely meet all required competencies.ConclusionCOVID-19 has had a negative impact on surgical training across all grades and specialties, with implications for trainee progression, recruitment and retention of the surgical workforce. Further investigation of the long-term impact at a national level is required.

Retrospective evaluation of association between perioperative antimicrobial protocol and complications following elective equine synovial endoscopy.

BackgroundProphylactic perioperative antimicrobial protocols in equine synovial endoscopy have been described but not compared with respect to post‐operative outcomes and complications. Increasing antimicrobial resistance in equine practice and interest in promoting judicious use of antimicrobials has prompted reevaluation of drug selection and dosing strategies.ObjectivesTo determine the frequency of and compare post‐operative complications following elective synovial endoscopy between horses receiving different perioperative antimicrobial protocols.MethodsRecords from the Colorado State University Veterinary Teaching Hospital were evaluated (2014–2018) and equine patients undergoing elective synovial endoscopy were identified. Patients undergoing endoscopy for sepsis or internal fixation were excluded. Patient signalment, clinician, joint and limb involved, perioperative antimicrobial regimen, number endoscopic portals and closure technique, and post‐operative complications including incidence of joint infection were recorded. Generalized linear models were used to estimate the odds of post‐operative complications.ResultsElective synovial endoscopies of 516 horses in 537 procedures evaluating 761 synovial structures were performed. No horses developed post‐operative septic synovitis. Administration of post‐operative antimicrobials, type used and patient sex were all significantly associated with increased risk of complications, which were predominantly gastrointestinal‐related. Complication rates in horses receiving a single preoperative dose of cefazolin were lower than in horses receiving potassium penicillin, gentamicin or multiple doses. Complication rates were lower in females compared to castrated or intact males. Other factors evaluated (breed, age, surgeon, anaesthesia duration or hospitalization, joint/limb operated, number endoscopic portals) were not associated with increased risk of complications post‐operatively in this case population.ConclusionsProphylactic perioperative antimicrobial protocols in equine practice deserve periodic reconsideration due to increased antimicrobial resistance. Prolonged antimicrobial usage beyond the time of surgery was unnecessary to prevent septic synovitis following synovial endoscopy in this case population and was furthermore associated with an increased risk of gastrointestinal complications.

A prospective observational cohort pilot study of the association between midazolam use and delirium in elderly endoscopy patients

BackgroundMidazolam is a benzodiazepine commonly used in procedural sedation and general anaesthesia. Current anaesthetic guidelines advise the avoidance of benzodiazepines in elderly patients due to concerns of an increased risk of delirium. Delirium is associated with significant patient morbidity and mortality, while also increasing health costs. Despite this, midazolam is often used in elderly patients undergoing low risk procedures due to the benefits of rapid onset, anxiolysis and haemodynamic stability compared to other sedatives. To date, studies describing the relationship between midazolam use and delirium in elderly patients undergoing low risk procedures, such as endoscopy, are limited.MethodThis was a prospective observational cohort pilot study identifying the prevalence of delirium pre-procedure and incidence of delirium post-procedure in elderly endoscopy patients receiving midazolam. The study population was elderly patients greater than 65 years of age, without underlying cognitive dysfunction, undergoing elective endoscopy. Electronic databases were used for collection of demographic and clinical information. Delirium was identified through the administration of the Family Confusion Assessment Method survey; this was administered to carers of the study population 24–48 h pre and post procedure to categorically identify the presence or absence of delirium.ResultsFifty-eight participants were recruited for this study and eighteen were subsequently excluded based upon additional exclusion criteria. Forty patients were included in the final results. American Society of Anaesthesiology Classification (ASA) of patients were as follows: 1 (9 patients), 2 (12 Patients), 3 (16 Patients) and 4 (3 patients). Patients underwent gastroscopy, colonoscopy or combined gastroscopy and colonoscopy. This study identified no cases of delirium in elderly patients after administration of midazolam for elective endoscopy procedures 24–48 h post-procedure. Additionally, a high proportion of elderly patients were found to have received midazolam.ConclusionNo episodes of delirium were identified in this study. This finding runs counter to current guideline recommendations regarding midazolam use in the elderly patient and that elderly patients undergoing elective endoscopy represent a significantly different patient population compared to those previously studied. This study suggests that in the study population that the risk of delirium in patients exposed to midazolam in elective endoscopy was not demonstrated and that it may be safe to perform experimental studies to elucidate the safety of midazolam in larger studies.

Is the choice of anesthesia during gastrointestinal endoscopic procedures a result of anxiety?

Background and study aimsEsophagogastroduodenoscopy (EGD) and colonoscopy (CS) are vital endoscopic procedures in the diagnosis and follow-up of gastrointestinal tract diseases. Endoscopic procedures can be performed with or without anesthesia as per patient preferences. These procedures can cause some anxiety in almost all patients, and the degree of anxiety differs for each individual. Thus, we aimed to evaluate the trait and state anxiety levels of the patients and assess the relationship between the preference of anesthesia and anxiety levels. Patients and methodsTo investigate this issue, 723 patients who underwent elective endoscopy (EGD and/or CS) were enrolled. The researchers collected sociodemographic data and medical history records as reported by the patients. State and trait anxiety levels of the patients were evaluated using the State and Trait Anxiety Inventory (STAI). ResultsThe patients were divided into two groups as with anesthesia and without anesthesia. Of the respondents, 43.4% requested anesthesia during endoscopic procedure. Sociodemographic data, except sex, showed similar characteristics. The STAI trait scores of the two groups were similar; however, there was a significant difference in the STAI state scores of the groups (p = 0.018). A significant difference was observed in the anesthesia preference and the type of endoscopic procedure (EGD, CS, or both) (p < 0.001). Type of endoscopic procedure, STAI state scores, and sex were determined as the predictors of the anesthesia choice. ConclusionEndoscopic procedures are known to cause anxiety among many patients. Our findings suggest that the anesthesia preferences of patients are an important factor in preventing these situational concerns. However, this study found that being a woman and undergoing a CS procedure are important factors related to anesthesia preferences. Thus, more detailed assessments on this subject are required.

The Impact of the COVID-19 Pandemic on Barrett’s Esophagus and Esophagogastric Cancer

The Impact of the COVID-19 Pandemic on Barrett’s Esophagus and Esophagogastric Cancer

Therapeutic Challenges in Post-Transplant Lymphoproliferative Disorder of the Esophagus with Central Nerve System Involvement Complicated by an Esophagotracheal Fistula: A Case Report

.1 Background: Post-transplant lymphoproliferative disorder (PTLD) is a known complication following solid organ or hematopoietic stem cell transplantation. It’s a heterogeneous group of lymphoid and/or plasmocytic proliferations as a result of immunosuppression and is frequently associated with Epstein-Barr Virus. The clinical presentation is nonspecific and highly variable depending on the localization. We discuss the therapeutic challenges in this rare case of a male suffering PTLD with esophageal involvement complicated by an esophagotracheal fistula. 1.2 Case Report: A 55-year-old man under immunosuppression after kidney transplantation, presented with progressive cough and fever after elective upper endoscopy. Following the diagnosis of diffuse large B cell lymphoma-type PTLD with esophagotracheal fistula. The reduction of immunosuppression was unable to control the progression of disease with involvement of the CNS. Endoscopic repair of the fistula was unsuccessful. The need for surgical repair of the fistula delayed therapy with rituximab by one month. Despite brain radiation therapy, the patient passed away 3.5 months after diagnosis. 1.3 Conclusion: In patients with esophagotracheal fistula both aspiration pneumonia and treatment of the fistula can delay effective treatment of the underlying malignant disease. In patients with PTLD reduction in immunosuppression is the primary treatment strategy, followed by monotherapy with the monoclonal antibody rituximab in the case of incomplete response. Newer therapeutic approaches prefer the sequential treatment with rituximab followed by chemotherapy in case of incomplete response, or consolidation therapy with rituximab in case of complete response. Radiotherapy is recommended in case of CNS involvement.

Patient Perspective on Safety of Elective Gastrointestinal Endoscopy During the COVID-19 Pandemic

BackgroundPatients’ perception regarding the risks of COVID-19 infection with gastrointestinal (GI) and the preventive measures taken in GI endoscopy units to mitigate infection risk remains unclear. We aimed to assess patients’ perception regarding risks of COVID-19 with GI endoscopy and the changes in the endoscopy unit as a result of the ongoing pandemic. MethodsOutpatients undergoing GI endoscopy at our institution were categorized into those scheduled to undergo GI endoscopy (preprocedure) and those who had recently undergone GI endoscopy during the pandemic (postprocedure). Two separate but similar survey instruments were designed. Patients were asked to respond on a 5-point Likert scale. Responses were stratified as “low,” “neutral,” and “high” for analysis. ResultsA total of 150 and 355 respondents completed the preprocedure and postprocedure surveys, with a combined response rate of 82.5%. Non-white ethnicity was associated with reporting a “high” level of concern for endoscopy related COVID-19 exposure in both the preprocedure (OR 4.09, 95% CI 1.54-10.82) and postprocedure cohorts (OR 2.11, 95% CI 1.04-4.29). 42% of patients in the preprocedure cohort and 11.8% in the postprocedure cohort reported their level of concern for COVID exposure as “high.” Among the postprocedure cohort, 88% of the patients were likely to undergo repeat endoscopy during the pandemic if recommended. ConclusionPatients are willing to undergo GI endoscopy during the COVID-19 pandemic. Non-white and older patients, and those undergoing screening examinations were more concerned with the GI endoscopy related COVID-19 transmission risk.

Effect of palatable lidocaine gel versus dexmedetomidine on gag reflex during propofol-based sedation for patients undergoing elective upper gastrointestinal endoscopy: a randomized controlled study

Background and objective Upper gastrointestinal tract endoscopy (UGIE) is widely performed under propofol sedation, which is considered as a safe sedation agent and alleviates the sympathetic response to the procedure. However, retching and gag reflex still disturb ∼29% of those patients despite being under propofol sedation. Patients and methods A total of 120 adult patients scheduled for elective UGIE were randomly allocated into three equal groups (40 patients each): group C was given propofol 50 mg, group D was given propofol 50 mg+dexmedetomidine 0.5 μg/kg, and group L was given propofol 50 mg+15 g palatable lidocaine gel. The outcome measures included incidence of gag reflex, propofol consumption, recovery time, intraoperative hemodynamics, and patients’ and endoscopist’s satisfaction. Results The incidence of gag reflex was statistically significantly reduced in groups L and D compared with group C; however, the reduction was more in group L but with no significant difference when compared with group D group. Propofol consumption was statistically significantly lower in groups L and D compared with group C, as well as recovery time was significantly shorter in groups L and D compared with group C. Group L showed the least hemodynamic changes among the three groups, and the endoscopist as well as the patients were statistically significant more satisfied in both groups L and D when compared with group C. Conclusion Using palatable lidocaine gel in addition to propofol in patients undergoing UGIE was safe and effectively reduced the incidence of gag reflex and the dose of intravenous propofol with its subsequent complications, shortening recovery time and improving patient and endoscopist satisfaction. Trial registration This clinical trial was registered with ClinicalTrials.gov (NCT04213833).

Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy

Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists

Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures. We conducted a multicenter, prospective, observational study from January 2018 to March 2020 of 1602 patients on oral anticoagulants (1004 on VKAs and 598 on DOACs) undergoing 1874 elective endoscopic procedures. Our primary outcomes were 90-day thromboembolic events and 30-day endoscopy-related gastrointestinal bleeding. The inverse probability of treatment weighting propensity score method was used for baseline covariate adjustment. The 2 groups had similar risks of endoscopy-related gastrointestinal bleeding (VKAs vs DOACs, 6.2% vs 6.7%; adjusted odds ratio [OR], 1.05; 95% CI, 0.67-1.65) and thromboembolic events (VKAs vs DOACs, 1.3% vs 1.5%; adjusted OR, 0.90; 95% CI, 0.34-2.38). In high bleeding risk procedures (n= 747), delayed anticoagulant resumption (> 48 hours or 24-48 hours vs < 24 hours) did not reduce the risk of postprocedural bleeding (10.3%, 9%, and 5.8%, respectively; adjusted P= .43). Hot and cold snare polypectomy were the most frequent high-risk interventions (41.8% and 39.8%, respectively). In a prospective study of patients on DOACs or VKAs undergoing elective endoscopy, endoscopy-related bleeding and thromboembolic events showed similar risk. Our study suggests that early anticoagulant resumption is safe in most patients, but more data are needed for advanced high-risk therapeutic procedures.

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis.

INTRODUCTION:Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients.METHODS:A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality.RESULTS:A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics.DISCUSSION:In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy.

Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.