Esophagogastroduodenoscopy Group Research Articles

The benefits of transnasal endoscopy compared to conventional endoscopy in adolescents

Background and aimTransnasal endoscopy (TNE) has been proven to reduce the need for intravenous anesthesia and the cost of the exams compared to conventional esophagogastroduodenoscopy (EGD) in adults. The objective of this study is to evaluate the benefits and the adverse effects of TNE in adolescents compared to conventional EGD. MethodsWe reviewed the pediatric patients from 2012 to 2022, who had undergone TNE at National Taiwan University Hospital due to epigastralgia. Age and gender-matched controls, who had undergone conventional EGD for epigastralgia at the same time, were also recruited. ResultsTotally 15 patients, aged between 12 and 20 years old, who had undergone TNE for epigastralgia at National Taiwan University Hospital were recruited as the study group. Another 60 age and gender-matched adolescents were also recruited in the control group. The needs of conscious sedation (9.3% vs 58.3%), hospitalization rate (13.3% vs 43.3%), the mean exam time (7.34 vs 9.96 min), and the cost of endoscopy (57.6 vs 93.2 USD) were significantly lower in the group of TNE as compared with the conventional EGD group. There was no difference in the percentage of complications, including dizziness, epistaxis, nausea, and vomiting, after procedures (P > 0.05.) ConclusionsTNE is a cost-effective exam and it also reduces the exposure to conscious sedation, the need for hospitalization and the exam time, making it a good choice for adolescents who are scheduled to undergo EGD for epigastralgia.

Real-World Outcomes of Atezolizumab with Bevacizumab Treatment in Hepatocellular Carcinoma Patients: Effectiveness, Esophagogastroduodenoscopy Utilization and Bleeding Complications.

The IMbrave150 trial established atezolizumab with bevacizumab (A+B) as standard care for hepatocellular carcinoma (HCC), recommending an esophagogastroduodenoscopy (EGD) within 6 months of treatment initiation to prevent bleeding from esophagogastric varices. The necessity of mandatory EGD for all patients remains unclear. We retrospectively analyzed 112 HCC patients treated with A+B at five Canadian cancer centers from 1 July 2020 to 31 August 2022. A+B was the first-line therapy for 90% of patients, with median overall survival at 20.3 months and progression-free survival at 9.6 months. There was no survival difference between patients with bleeding and those without. Before A+B, 71% (n = 79) of patients underwent an EGD within 6 months, revealing varices in 41% (n = 32) and requiring intervention in 19% (n = 15). The overall bleeding rate was 15% (n = 17), with GI-specific bleeding occurring in 5% (n = 17). In the EGD group, GI-specific bleeding was 6% (n = 5) while in the non-EGD group, it was 3% (n = 1). Non-GI bleeding was observed in 10% (n = 11) of patients. Outcomes for HCC patients treated with A+B in Canada were comparable to IMbrave150. There was no increase in GI bleeding in patients without pre-treatment EGD, possibly supporting a selective EGD approach.

Abstract 4794: Impact of prior upper endoscopy on gastric cancer stage and survival

Abstract Background: While gastric cancer (GC) incidence in the US has decreased, 5-year survival remains at 34.5%. Early diagnosis offers curative or treatable options, yet many cases are detected at an advanced stage with poor prognosis. In high-incidence East Asian countries with established screening programs, endoscopic screening demonstrates stage shift towards early GC diagnosis and reduced GC-related mortality. Analyses of these programs have reported benefit of endoscopic screening up to 36 months prior to diagnosis. This study explores the impact of esophagogastroduodenoscopy (EGD) in this timeframe on GC stage at diagnosis and survival in an older US population. Methods: The SEER-Medicare database was queried from 2000 to 2017 for patients 68 years of age or older with histologically confirmed GC with continuous Medicare enrollment for at least 36 months prior to GC diagnosis. We excluded patients with prior cancer history and those diagnosed by autopsy or death certificate. Medicare claims files were searched for EGD claims 6-36 months prior to GC diagnosis. We excluded claims in the 6 months prior to diagnosis to avoid capturing potential diagnostic EGD. We defined the exposed group as patients with an EGD claim 6-36 months prior to GC diagnosis (Prior EGD) and the unexposed group as patients with no EGD claim in this period (No Prior EGD). Propensity score analysis balanced baseline differences for patients with and without Prior EGD using covariates sex, age and year of diagnosis, race and ethnicity, rural/urban, comorbidity, SES, and marital status. The primary outcome was in situ/local-stage GC (early) at diagnosis compared to regional/distant-stage (advanced). Secondary outcomes were 5-year overall and GC-specific survival. The adjusted odds of having in situ/local-stage GC diagnosis compared to regional/distant-stage was estimated using logistic regression, and survival analysis was done using the Kaplan-Meier method. Results: In 10,572 patients with GC (57.5% male, mean age 78.8 years), 16.4% had Prior EGD (n=1,736). Patients with Prior EGD had a significantly higher proportion of GC diagnosed in local stage compared to patients with No Prior EGD (45.7% vs. 30.2%, p < 0.001). After controlling for confounders, Prior EGD group had two-fold increased odds of GC diagnosis at early-stage compared with No Prior EGD (OR=1.99, 95% CI: 1.88-2.10). Compared with No Prior EGD, Prior EGD was associated with higher overall survival (5-year survival 32.1% vs. 22.7%, p<0.001) and GC-specific survival (5-year survival 46.0% vs. 31.1%, p<0.001), both driven by early-stage disease. Conclusions: Our analysis demonstrates that EGD up to 36 months prior to the diagnosis of GC is associated with earlier stage at diagnosis and improved overall and GC-specific survival. This study of an older population suggests that endoscopic screening may be beneficial even in a low-incidence country such as the US and warrants further study. Citation Format: Sophie Wagner, Jennifer S. Ferris, Josephine Soddano, Ji Yoon Yoon, Sheila D. Rustgi, Haley Zylberberg, Jeong Yun Yang, Yongmei Huang, Ling Chen, Chin Hur. Impact of prior upper endoscopy on gastric cancer stage and survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4794.

Are alarm symptoms of the Rome IV criteria enough to rule out organic pathology?

The Rome IV criteria offer symptom-based recommendations for diagnosing functional gastrointestinal diseases (FGID) in children and adolescents without esophagogastroduodenoscopy (EGD). The aim of this study is to evaluate the usefulness of Rome IV criteria for ruling out organic disease in patients with and without alarm symptoms. Retrospective research was conducted on children and adolescents who had dyspepsia and underwent EGD. The patients were categorized into groups according to the Rome IV criteria, based on the presence or absence of alarm signs. The esophagogastroduodenoscopy findings in these groups were then compared and classified as either altered or normal. Seventy-seven of 124 cases (62%) had altered EGD findings, and 97.2% (75/77) of altered EGD patients had histopathological findings. In the study population, the prevalence of Helicobacter pylori was 46.7%. Seventy-four of 124 cases (59.7%) had no alarm symptoms and were diagnosed with FGID according to Rome IV criteria. Thirty-six (48%) of these patients had altered EGD, and five of these patients had duodenal ulcers. Patients without alarm symptoms were compared based on altered versus normal EGD findings. Helicobacter pylori was significantly more abundant in the altered EGD group. Fifty (40.3%) of 124 patients had one or more alarm symptoms and 41 of 50 (82%) cases with alarm symptoms had altered EGD. When patients with altered and normal EGD findings were compared, alarm symptoms, H. pylori, and histopathological findings were higher in the altered EGD group. The Rome IV criteria are effective for alarm-symptom-positive patients. However, in patients lacking alarm symptoms, the Rome IV criteria are insufficient to rule out organic causes.

Real-world multicentre analysis of patients with hepatocellular carcinoma (HCC) treated with atezolizumab and bevacizumab (A+B): Efficacy, esophagogastroduodenoscopy (EGD) uptake and bleeding complications.

4105 Background: The IMbrave150 trial established A+B as a standard of care for HCC and an EGD within 6 months (mos) of starting treatment to detect esophagogastric varices and prevent bleeding complications was advised. However, the value of performing EGD in all patients (pts) is unknown. Methods: We conducted a retrospective analysis of all HCC pts treated with A+B between July 2020 to August 2022 at 5 cancer centres from the Canadian provinces of Ontario, Alberta and Manitoba (members of the HCC-CHORD Consortium). Pts characteristics and treatment history including efficacy, EGD details and bleeding events were collected. Overall survival (OS), progression-free survival (PFS) and response rate (RR) were calculated. A comparative analysis was conducted to compare the correlation between the EGD uptake and bleeding events. Results: A total of 112 pts were identified (median age 66 years, 87% male, 24% East Asian, 67% liver cirrhosis, 33% HCV, 25% HBV, 15% NASH, 23% BCLC B, 71% BCLC C, 91% Child-Pugh A, 29% main portal vein invasion, 45% ALBI grade 1 and 54% ALBI grade 2). Prior to systemic, 61% had locoregional therapies. 90% received A+B as first-line therapy, while 9% received it as second-line and 1% as third-line. Outcomes of pts treated with A+B are shown. Before starting A+B, 78 pts (70%) had completed an EGD within 6 mos. Of these, 32 pts (41%) had evidence of varices on EGD, and 15 (20%) required treatment with either banding or beta-blockers. All bleeding events in this population was 15% (n=17). Bleeding rates in the EGD and non-EGD groups were 18% (n=14) and 9% (n=3), respectively. Bleeding adverse events were 5%(n=6) gastrointestinal vs 10%(n=11) non-gastrointestinal (6 epistaxis, 1 ecchymosis, 1 periodontal and 3 unspecified). The GI bleeding rates in the EGD and non-EGD groups were 6% (n=5) and 3% (n=1). Conclusions: Outcomes of HCC pts treated with A+B in Canada are comparable to those observed in the IMbrave150 trial. Our study detected and treated varices at twice the rate of the IMbrave150 trial among the EGD group, reflecting real-world treatment of a high-risk population. Yet, pts who had no EGD before starting A+B, presumably due to a low risk of portal hypertension based on physicians’ judgement, did not experience more bleeding/GI bleeding than those who had an EGD. This supports the approach of selective EGD prior to A+B, and more guidelines are needed in this area. Outcomes and response rate of patients(pts) treated with Atezolizumab with Bevacizumab in this study. [Table: see text]

The Clinical Dilemma of Esophagogastroduodenoscopy for Gastrointestinal Bleeding in Cardiovascular Disease Patients: A Nationwide-Based Retrospective Study.

Performing esophagogastroduodenoscopy (EGD) in recently occurring peri-coronary artery disease (CAD) accident settings is always a dilemma. This study used the Taiwan National Health Insurance Research Database to identify patients with CAD and gastrointestinal bleeding who had received EGD or not between 2000 and 2013.The final population included in this study was 15,147 individuals, with 3801 individuals having received EGD (study cohort group) and 11,346 individuals not having received EGD (comparison cohort group). We initially performed a sensitivity test for CAD recurrence-related factors using multivariable Cox regression during the tracking period. A relatively earlier EGD intervention within one week demonstrated a lower risk of CAD recurrence (adjusted HR = 0.712). Although there were no significant differences in the overall tracking period, the adjusted HR of CAD recurrence was still lower in patients in the EGD group. Furthermore, our findings revealed that there were no remarkably short intervals to CAD recurrence in the study group. The Kaplan–Meier survival curve demonstrated that individuals who underwent EGD were not associated with a significantly increased CAD recurrence rate compared with the control (Log-rank test, p = 0.255). CAD recurrence is always an issue in recent episodes of peri-CAD accident settings while receiving EGD. However, there is not a higher risk in comparison with the normal population in our study, and waiting periods may not be required.

Gastrointestinal Symptomatology as a Predictor of Esophagogastroduodenoscopy Findings in the Bariatric Population: a Retrospective Cohort Study with Review of the Literature.

Esophagogastroduodenoscopy (EGD) is a useful test to diagnose significant pathologies before bariatric surgery. Controversy remains about its role in the preoperative workup of asymptomatic patients. This study aims to describe findings and changes in the management related to EGD. A secondary objective was to review the existing literature on the subject to analyze the role of patients' gastrointestinal symptomatology as an indication to undergo a preoperative EGD. A retrospective chart review of patients operated at the Centre hospitalier universitaire de Sherbrooke (CHUS) since the opening of the Clinique médico-chirurgicale du traitement de l'obésité (CMCTO) was conducted, alongside a review of the literature. Pathologic findings on EGD were classified into 4 groups (groups 0 to 3). Results of this study were combined with literature to calculate weighted averages of global sensitivity, specificity, positive/negative predictive values, and likelihood ratios of gastrointestinal symptomatology as a predictor of pathologic endoscopy findings. A total of 737 patients were included in the study. Of those, 236 (35,7%) were considered symptomatic. Significant pathologic findings on EGD (group 2 and 3) were present for 270 patients (36.6%). Changes in medical management occurred in 22.8% of cases and in surgical management in 3.5% of cases. When combining past studies with the present one, the presence of symptoms had a sensitivity of 57.4% and a specificity of 82.4% for findings on EGD. Considering that this exam is relatively safe, that it allows uncovering a great number of pathologies altering management, and that symptoms are not a good screening test to decide of its indication, the authors recommend that all bariatric surgery patients undergo an EGD in their preoperative workup.

Clinical outcomes of esophagogastroduodenoscopy in critically ill patients using high-dose proton pump inhibitor for suspected bleeding: A retrospective cohort study.

Esophagogastroduodenoscopy (EGD) is a useful procedure performed for gastrointestinal (GI) bleeding. No definite clinical guidelines recommend EGD implementation in intensive care unit (ICU) patients with suspected GI bleeding. The objective of this study was to compare the clinical effectiveness of EGD in critically ill patients who are using high-dose proton pump inhibitor (PPI) for suspected GI bleeding.We retrospectively analyzed ICU patients using high-dose PPI for suspected GI bleeding from January 2012 to September 2020. Major cases of GI bleeding, such as those with hematemesis and hematochezia, were excluded, and 1:1 propensity score matching was performed. The change in hemoglobin level, requirement of red blood cell transfusion, re-suspected bleeding event, length of ICU stay, and ICU mortality were compared between the EGD and non-EGD groups.Of the 174 subjects included, 52 patients underwent EGD within 24 hours of PPI administration. In the EGD group, 22 (42.3%) patients showed normal findings, while esophagitis and gastritis were most common abnormal finding (n = 11, 21.2%), and 14 patients (26.9%) underwent a hemostatic procedure. While comparing the 2 groups, the EGD group required a higher amount of red blood cell transfusion (packs) than the non-EGD group for a week (3.04 ± 0.44 vs 2.07 ± 0.25, P = .01). There was no significant difference in the change in hemoglobin level after 1 week (P = .15). After propensity score matching, the EGD group showed similar the requirement of red blood cell transfusion and change in hemoglobin level for a week (P = .52, P = .97, respectively). In analyses for all patients and propensity score matched patients, there was no statistically significant difference in term of re-suspected bleeding event rate, duration of ICU stay, and ICU mortality. However, re-suspected bleeding event rate and ICU mortality were lower trend in the EGD group than the non-EGD group.This study showed that EGD had no definite clinical benefit in ICU patients using high-dose PPI for suspected GI bleeding and aggressive EGD is not necessarily recommended. However, it is necessary to consider EGD in patients who are tolerant.

Pros and Cons of Performing Early Endoscopy in Geriatric Patients Admitted with Non-variceal Upper Gastrointestinal Bleeding: Analysis of the US National Inpatient Database.

Age greater than 65years is a well-defined risk factor for increased mortality in patients with non-variceal upper gastrointestinal bleeding (NVGIB). Endoscopy is indicated in most patients at any age but presents unique risks in the elderly cohort, and ideal timing is unclear. This study examined the association between outcomes and early (within 24h) esophagogastroduodenoscopy (EGD) among elderly patients with NVGIB. All patients over age 65 admitted primarily for NVGIB who underwent EGD were included from the National Inpatient Sample 2016-2017. Clinical outcomes stratified by early EGD versus late EGD were compared after adjustment for comorbidities and bleeding severity using inverse probability of treatment weighting with survey-adjusted linear and logistic regression. Out of estimated 625,530 admissions with a primary diagnosis of NVGIB, 120,835 met eligibility criteria; 24,830 underwent early EGD. Mean length of stay and total charges decreased by 1.17days (95%CI 1.04-1.30, P < 0.001) and $5717.24 (95%CI 4034.57-7399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95%CI 1.06-1.64, P 0.01) and transfer to other hospitals 1.48 (95%CI 1.22-1.81, P < 0.001). No change was seen in the requirement for surgery or angiography. Rates of discharge to a nursing facility or home health were similar. In a comprehensive cohort of geriatric patients with NVGIB, early EGD is associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer. Further research is needed to determine the optimal management of this vulnerable population.

Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines.

National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.

Impact of endoscopic sedation on gastric polyp detection: A one-center retrospective observational study.

Sedation esophagogastroduodenoscopy (EGD) has become more prevalent in many countries. However, owing to the limitation of health insurance payment for sedation EGD in Taiwan, non-sedation EGD still accounts for the majority of cases. This study was aimed to explore the differences between the sedation and non-sedation groups in terms of endoscopic findings, such as detection rate of gastric polyp of any size, number of detected gastric polyps, and location of the gastric polyps detected.We enrolled 10,940 patients who underwent EGD between January 1, 2016 and December 31, 2016 at the Tri-Service General Hospital; among the patients, 1900 received intravenous sedation (IVS) and 9040 did not. The data reviewed included demographics, parameters of the polyp (number, size, and location), and pathology.Compared with the non-sedation group, the sedation group had a higher overall polyp detection rate (P < .001); a greater number of detected polyps (Odds ratio 1.50, P = .007); and a higher detection rate of smaller polyps, such as fundic gland polyp, and hyperplastic polyp (P < .001). Among the pathological findings, gastric neuroendocrine tumor (NET) was detected using EGD in 2 cases and manifested as small polyps (<0.05 cm), and it showed significantly better detection rates in the sedation EGD group than in the non-sedation EGD group (P = .002).Sedation EGD could enhance a patients willingness and cooperation during EGD. Furthermore, sedation EGD increased the detection rates of small gastric polyps and was more likely to enable identification of unusual findings, such as gastric NET.

S0596 Is Early Inpatient Endoscopy Necessary for Anticoagulant-Associated Gastrointestinal Bleeding?

INTRODUCTION: Patients on systemic anticoagulation are at increased risk for gastrointestinal bleeding (GIB). In those that present with GIB, resuscitation and support remain the standard of care. Guidelines also recommend endoscopy within 24 hours for diagnostic and therapeutic purposes. Unfortunately, lack of resources and/or gastroenterologists in small, community centers limit the ability to perform timely endoscopy. Conservative management is used in this setting with delayed or outpatient endoscopy, specifically in those who respond to medical therapy. There is minimal data on the outcomes of patients managed in this fashion. We look to compare presentation and outcomes of patients on anticoagulation who present with non-variceal upper GIB in a small community hospital. METHODS: We conducted a retrospective review of 115 patients with non-variceal upper GIB who underwent medical therapy (MT) alone vs inpatient endoscopy with MT. Outcomes included red blood cell (RBC) transfusions, re-admission for GIB, and 30-day all-cause mortality. Sub-group analysis was also performed based on endoscopy timeline and anticoagulant type. RESULTS: The MT group was comprised of 54 patients while 61 patients underwent inpatient esophagogastroduodenoscopy (EGD). There were no difference in age, gender, baseline laboratory values, or co-morbidities between both groups. Patient in the MT group required less RBC transfusions compared to EGD group (1.4 vs 2.5 average units, P = 0.004). There was no significant difference in the re-admission for GIB and overall mortality. There were 3 deaths, one in the endoscopy group (<24 hours) and 2 in the MT group (P = 0.60). Most patients were on warfarin (n = 47) and there were no differences in re-admission for GIB or mortality based on anticoagulant type. CONCLUSION: We aimed to evaluate outcomes in patients on chronic anticoagulation with non-variceal UGIB at a small, community medical center where urgent endoscopy cannot always be performed. In this retrospective study, we found that patients receiving MT only required significantly fewer blood transfusions than those undergoing endoscopy with no difference in recurrent GIB or mortality. Our study suggests that in a small, community center, conservative management could be employed safely if urgent endoscopy is not available. Nevertheless, a randomized, large study is needed to substantiate this claim.Table 1.: Demographic data comparing endoscopy group with Medical Therapy only groupFigure 1.: Average number of packed red blood cell transfusions was greater with endoscopy.Table 2

Which scope is appropriate for endoscopic retrograde cholangiopancreatography after Billroth II reconstruction: An esophagogastroduodenoscope or a colonoscope?

BACKGROUNDRecently, with the advent of more advanced devices and endoscopic techniques, endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II (B-II) patients has been increasingly performed. However, the procedures are difficult, and the techniques and strategies have not been defined.AIMTo reveal the appropriate scope for ERCP in B-II patients.METHODSSixty ERCP procedures were performed on B-II patients between June 2005 and May 2018 at Fukushima Medical University Hospital, and in 44 cases, this was the first ERCP procedure performed by esophagogastroduodenoscopy (EGDS) or colonoscopy (CS) after B-II gastrectomy. These cases were divided into two groups: 17 cases of ERCP performed by EGDS (EGDS group) and 27 cases of ERCP performed by CS (CS group). The patient characteristics and ERCP procedures were compared between the EGDS and CS groups.RESULTSThe procedural time was significantly shorter in the EGDS group than in the CS group [median (range): 60 (20-100) vs 90 (40-128) min, P value < 0.01]. CS was an independent factor of a longer ERCP procedural time according to the univariate and multivariate analyses (odds ratio: 3.97, 95%CI: 1.05-15.0, P value = 0.04).CONCLUSIONCompared to CS, EGDS shortened the procedural time of ERCP in B-II patients.

Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy.

Endoscopic evaluation is frequently performed before bariatric surgery to identify foregut pathology that may alter procedure selection. Transnasal endoscopy (TNE) is an alternative to esophagogastroduodenoscopy (EGD). The objective of this study was to compare TNE to EGD. Patients who underwent TNE or EGD before bariatric surgery from January 2012 through April 2019 were reviewed. Statistical analyses included Chi-square, Wilcoxon two-sample, and Fisher's exact tests. A p value < 0.05 was considered significant. Three hundred and forty-five patients underwent preoperative screening (63% EGD, 37% TNE) before bariatric surgery. Mean age and preoperative body mass index in the TNE and EGD groups were 46.2 ± 12.4 vs 45.5 ± 11.6years (p = 0.58) and 46.5 ± 7.1 vs. 45.5 ± 6.1kg/m2 (p = 0.25), respectively. Three TNEs were aborted, resulting in a success rate of 98%. Of patients who underwent EGD, 1 (0.5%) visited the emergency department (ED), and 7 (3%) called the nurse with post-procedure concerns. There were no ED visits or nurse calls from patients who underwent TNE. The median total time in the procedure room was 77 (57-97) min for EGD vs. 26 (8-33) min for TNE (p < 0.001). One patient who underwent TNE required subsequent EGD. Mean charge per patient for EGD and TNE was $5034.70 and $1464.00, respectively. TNE was associated with less post-procedure care, shorter procedure time and fewer charges compared to EGD. TNE could be considered an initial screening tool for patients undergoing bariatric surgery, while EGD could be used selectively in patients with abnormal TNE findings.

Outcomes of Upper Gastrointestinal Bleeding Based on Time to Endoscopy: A Retrospective Study.

IntroductionNon-variceal upper gastrointestinal bleeding (UGIB) is a major burden on the health care system. The timing of endoscopy has been an ongoing debate and data on the association of early endoscopy with a better or worse clinical outcome are conflicting. In our study, we aimed to identify the benefits versus the risks of performing an urgent endoscopy in regards to the number of endoscopic interventions, length of hospital stay, number of packed red blood cells (PRBCs) transfused, and mortality. MethodologyThis is a retrospective record-based study. A total of 806 charts were reviewed and 251 patients with the signs and symptoms of UGIB on presentation were included in the study. Patients with variceal bleeding, lower gastrointestinal bleeding, insignificant bleeds with no drop in H/H, GI bleed not being the presenting complaint on admission, and patients on anticoagulation were excluded.ResultsOut of the patients who underwent an urgent esophagogastroduodenoscopy (EGD), 26.2% needed a second-look EGD 48 hours after the first EGD when compared to 4% and 2% in the early (12-24 hours) and late (>24 hours) endoscopy groups, respectively. In patients who underwent urgent EGD, 23% had active bleeding and it was statistically significant when compared to the other groups. The active bleeding limited the visualization during the endoscopy, which led to a repeat EGD in the urgent EGD group. If an endoscopic intervention was received, patients having EGD >24 hours received a smaller number of interventions. There was no statistical difference in the Blatchford scores between the three groups, indicating that the groups were similar in morbidity. No difference in mortality, hospital length of stay, or number of blood transfusions received, surgical or interventional radiology-guided interventions was found between the three groups.ConclusionPatients who underwent urgent endoscopy had more procedures, with no difference in mortality, number of units of blood transfused, or length of hospitalization when compared to the early or late endoscopy groups.

Usefulness of Full-spectrum Endoscopy for the Upper Gastrointestinal Tract.

We determined whether full-spectrum endoscopy (FUSE) improved the visualization rates of blind spots in a single-center case control study. FUSE provides a 210-degree angle of view with a left side-viewing camera in addition to a forward-viewing camera. FUSE can improve the detectability of blind spots in conventional forward-viewing esophagogastroduodenoscopy (EGD), such as the major duodenal papilla (MDP) and the anal side of the pyloric ring. Between April 2016 and May 2017, successful visualization rates of the whole MDP and anal side of the pyloric ring were compared between 103 participants who underwent FUSE and 1045 participants who underwent EGD. Pain and discomfort at insertion and during and after the examination were assessed using a visual analog scale in 38 participants who underwent FUSE with a previous examination history of EGD. The successful visualization rates of MDP and the anal side of the pyloric ring in the FUSE group were significantly higher than those in the conventional EGD group; 83.4% versus 35.1% for MDP (P<0.001) and 86.4% versus 7.1% for the anal side of the pyloric ring (P<0.001), respectively. The visual analog scale were not significantly different between FUSE and previous EGD in a portion of the FUSE group. In addition, the detection rate of the periampullary diverticula was also significantly higher in the FUSE group than that in the conventional EGD group (8.7% vs. 1.6%, P<0.001). This study provides evidence supporting that FUSE is superior to EGD for precise visualization of blind spots in the duodenum.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

AimTo evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).Materials and methodsAfter Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.ResultsA total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.ConclusionPreoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.

Patient response prediction with logistic regression in gastrointestinal endoscopy under midazolam-alfentanil sedation performed as well as response surface model

BackgroundResearchers have used logistic regression (LR) and non-linear response surface models (RSMs) to predict patient responses to sedation. The reduced Greco and hierarchy RSMs have proven to be more appropriate than other RSMs in gastrointestinal endoscopies using midazolam and alfentanil. In this study, we evaluate the performance of a simpler model, LR, and compared it with that of RSM. MethodsThirty-three patients who received esophagogastroduodenoscopy (EGD) and colonoscopy sedation with midazolam and alfentanil were enrolled in the study. LR was performed for the EGD group and validated using the colonoscopy group. The two RSMs were performed using the same process, and performances and receiver operating characteristic (ROC) curves of the models were evaluated. ResultsThe native EGD LR model had an ROC curve area of 0.94. For external validation, the ROC curves were 0.92, 0.94, and 0.94 for the reduced Greco, hierarchy, and LR models, respectively. Pairwise comparison between models was not significant. ConclusionThe LR model performed as well as RSM in generalizing the predicted sedative effect of midazolam and alfentanil during gastrointestinal endoscopies. LR may be used for generalization across patients experiencing procedures with similar stimulus intensities.

Early versus late bedside endoscopy for gastrointestinal bleeding in critically ill patients

Background/AimsGastrointestinal (GI) bleeding is a life-threatening complication in critically ill patients. The aim of this study was to determine the efficacy of bedside endoscopy in an intensive care unit (ICU) setting, and to compare the outcomes of early endoscopy (within 24 hours of detecting GI bleeding) with late endoscopy (after 24 hours).MethodsWe retrospectively reviewed the medical records of patients who underwent bedside endoscopy for nonvariceal upper GI bleeding and lower GI bleeding that occurred after ICU admission at Seoul National University Hospital from January 2010 to May 2015.ResultsTwo hundred and fifty-three patients underwent bedside esophagogastroduodenoscopy (EGD) for upper GI bleeding (early, 187; late, 66) and 69 underwent bedside colonoscopy (CS) for lower GI bleeding (early, 36; late, 33). Common endoscopic findings were peptic ulcer, and acute gastric mucosal lesion in the EGD group, as well as ischemic colitis and acute hemorrhagic rectal ulcers in the CS group. Early EGD significantly increased the rate of finding the bleeding focus (82% vs. 73%, p = 0.003) and endoscopic hemostasis (32% vs. 12%, p = 0.002) compared with late EGD. However, early CS significantly decreased the rate of identifying the bleeding focus (58% vs. 82%, p = 0.008) and hemostasis (19% vs. 49%, p = 0.011) compared with late CS due to its higher rate of poor bowel preparation and blood interference (38.9% vs. 6.1%, p = 0.035).ConclusionsEarly EGD may be effective for diagnosis and hemostatic treatment in ICU patients with GI bleeding. However, early CS should be carefully performed after adequate bowel preparation.

How to improve patient satisfaction during midazolam sedation for gastrointestinal endoscopy?

AIMTo determine the procedure-related factors that affect sedation satisfaction and to make a suggestion to improve it.METHODSWe prospectively enrolled a total of 456 patients who underwent outpatient endoscopy procedures with midazolam sedation between March 2014 and August 2014. All patients completed both pre- and post-endoscopy questionnaires about sedation expectations and satisfaction.RESULTSThe study cohort included 167 (36.6%) patients who underwent esophagogastroduodenoscopy (EGD), 167 (36.6%) who underwent colonoscopy, and 122 (26.8%) who underwent a combined procedure (EGD and colonoscopy). Over 80% of all patients were satisfied with sedation using midazolam. In univariate and multivariate analyses, total procedure time in the EGD group, younger age (≤ 50 years), and longer colonoscopy withdrawal time in the colonoscopy group were related to decreased satisfaction with sedation. However, in active monitoring and intervention group, there was no decrease in grade of satisfaction despite longer procedure time due to more procedures during colonoscopy. Younger age (≤ 50 years), longer inter-procedure time gap, and colonoscopy withdrawal time were related to decreased satisfaction in the combined EGD and colonoscopy group.CONCLUSIONMidazolam is still a safe and effective sedative for gastrointestinal endoscopy. Satisfaction with sedation depends on several factors including age (≤ 50 years) and procedure time duration. To improve patient satisfaction with sedation, active monitoring of sedation status by the endoscopist should be considered for patients who require long procedure time.