Endoscopy Guidelines Research Articles

Effects of Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment on Postoperative Bleeding after Endoscopic Submucosal Dissection for Early Gastric Cancer: A Propensity Score-Matching Analysis

Background: Management of antithrombotic agents during endoscopic treatment changed after the publishing of ­Japan Gastroenterological Endoscopy Society guidelines for gastroenterological endoscopy in antithrombotic drug users (GL-2012). Objectives: We aimed to evaluate the effect of implementing antithrombotic agent management guidelines (GL-2012) on postoperative bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and on the prevention of thromboembolic events. Methods: A total of 1,264 patients who underwent ESD for EGC at Kyoto Prefectural University Hospital between June 2002 and March 2017 were enrolled and divided into 2 groups: 621 patients before the publication of GL-2012 (Pre-GL group) and 643 patients after (Post-GL group). Relationships between postoperative bleeding and various clinicopathological factors in each group were investigated through propensity score-matching analysis. Results: In the Pre-GL group, antihypertensive agent use (p < 0.01) and upper third of the stomach (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 4.6, 95% CI 1.6–12.8) and upper third of the stomach (OR 4.9, 95% CI 1.8–13.4) were significantly related to postoperative bleeding in multivariate analysis. In the Post-GL group, antihypertensive agent use (p < 0.01), dual antiplatelet agents use (p < 0.01), anticoagulant agents use (p < 0.01), and heparin replacement therapy (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 3.4, 95% CI 1.1–9.6), dual antiplatelet agents (OR 12.3, 95% CI 2.4–63.0), and heparin replacement therapy (OR 10.2, 95% CI 2.5–41.5) were significantly related to postoperative bleeding in multivariate analysis. Conclusions: The adherence to GL-2012 might reduce risk of thromboembolic events. On the other hand, dual antiplatelet agents therapy and heparin replacement therapy were the new independent risk factors for ESD postoperative bleeding in EGC after GL-2012. Especially as for heparin replacement therapy, uninterrupted warfarin or a temporary short interruption of direct oral anticoagulants without heparin replacement therapy might be recommended rather than heparin replacement therapy.

Undisclosed payments by pharmaceutical and medical device manufacturers to authors of endoscopy guidelines in the United States

Payments from pharmaceutical and medical device manufacturers to authors of clinical practice guidelines (CPGs) may influence practice recommendations. It is therefore important to evaluate the completeness of financial conflict of interest (FCOI) declarations among CPG authors. We performed a cross-sectional analysis of industry payments to authors of endoscopy guidelines published by 5 GI societies between 2014 and 2017. For each author we identified payments using the disclosure section of CPGs and the Centers for Medicare & Medicaid Services Open Payments (CMS-OP) database. We calculated the prevalence, monetary value, and type of declared and undeclared payments among authors. Payments were assessed for the calendar year of and before publication. Thirty-seven CPGs were included in the analysis comprising 569 author entries (91 unique individuals; 66.43% men, 92.6% physicians, 66.4% academically affiliated). Four hundred fifty-one episodes (79%) involved FCOIs, 451 (79%) had undisclosed FCOIs in the CMS-OP, and 445 (77%) had FCOIs relevant to a CPG recommendation. The median undisclosed payment value was $4807.26 (interquartile range, $334.84-$20,579.75). Male authors (odds ratio, 2.23; 95% confidence interval, 1.47-3.39) and academically affiliated authors (odds ratio, 8.87; 95% confidence interval, 5.57-14.13) were significantly more likely to have undeclared payments (P< .001). No CPGs metall National Academy of Medicine criteria. Recognizing concerns about the accuracy of the CMS-OP, there are substantial discrepancies between industry-reported payments and author self-disclosure. Additionally, there is a high prevalence of undisclosed payments by pharmaceutical and medical device manufacturers to these authors. Given the potential impact of these discrepancies and undisclosed payments on CPGs, more accurate reporting and alternative strategies for managing FCOI are needed.

Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019.

1: ESGE suggests that high definition endoscopy, and dye or virtual chromoendoscopy, as well as add-on devices, can be used in average risk patients to increase the endoscopist's adenoma detection rate. However, their routine use must be balanced against costs and practical considerations.Weak recommendation, high quality evidence. 2: ESGE recommends the routine use of high definition systems in individuals with Lynch syndrome.Strong recommendation, high quality evidence. 3: ESGE recommends the routine use, with targeted biopsies, of dye-based pancolonic chromoendoscopy or virtual chromoendoscopy for neoplasia surveillance in patients with long-standing colitis.Strong recommendation, moderate quality evidence. 4: ESGE suggests that virtual chromoendoscopy and dye-based chromoendoscopy can be used, under strictly controlled conditions, for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps and can replace histopathological diagnosis. The optical diagnosis has to be reported using validated scales, must be adequately photodocumented, and can be performed only by experienced endoscopists who are adequately trained, as defined in the ESGE curriculum, and audited.Weak recommendation, high quality evidence. 5: ESGE recommends the use of high definition white-light endoscopy in combination with (virtual) chromoendoscopy to predict the presence and depth of any submucosal invasion in nonpedunculated colorectal polyps prior to any treatment. Strong recommendation, moderate quality evidence. 6: ESGE recommends the use of virtual or dye-based chromoendoscopy in addition to white-light endoscopy for the detection of residual neoplasia at a piecemeal polypectomy scar site. Strong recommendation, moderate quality evidence. 7: ESGE suggests the possible incorporation of computer-aided diagnosis (detection and characterization of lesions) to colonoscopy, if acceptable and reproducible accuracy for colorectal neoplasia is demonstrated in high quality multicenter in vivo clinical studies. Possible significant risks with implementation, specifically endoscopist deskilling and over-reliance on artificial intelligence, unrepresentative training datasets, and hacking, need to be considered. Weak recommendation, low quality evidence.

Czech Society of Gastroenterology guidelines for capsule endoscopy

Czech Society of Gastroenterology guidelines for capsule endoscopy

Endoscopic management of Lynch syndrome and of familial risk of colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

ESGE recommends that individuals with Lynch syndrome should be followed in dedicated units that practice monitoring of compliance and endoscopic performance measures.Strong recommendation, low quality evidence, level of agreement 100 %.ESGE recommends starting colonoscopy surveillance at the age of 25 years for MLH1 and MSH2 mutation carriers and at the age of 35 years for MSH6 and PMS2 mutation carriers.Strong recommendation, moderate quality evidence, level of agreement 100 %. ESGE recommends the routine use of high-definition endoscopy systems in individuals with Lynch syndrome. Strong recommendation, high quality evidence, level of agreement 100 %. ESGE suggests the use of chromoendoscopy may be of benefit in individuals with Lynch syndrome undergoing colonoscopy; however routine use must be balanced against costs, training, and practical considerations.Weak recommendation, moderate quality evidence, level of agreement 89 %.ESGE recommends definition of familial risk of colorectal cancer as the presence of at least two first-degree relatives with colorectal cancer or at least one first-degree relative with colorectal cancer before the age of 50 years.Strong recommendation, moderate quality evidence, level of agreement 92 %.ESGE recommends colonoscopy surveillance in first-degree relatives of colorectal cancer patients in families that fulfill the definition of familial risk of colorectal cancer.Strong recommendation, moderate quality evidence, level of agreement 100 %.

878 Prophylactic Antibiotic Administration in EUS-Guided Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION: EUS guided fine needle aspiration (FNA) of pancreatic cystic lesions (PCL) has become the standard diagnostic modality for pancreatic cysts. Current American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommended the use of periprocedural prophylactic antibiotics (PA), although data is equivocal. Our aim was to perform a systematic review and meta-analysis to evaluate the efficacy of PA in preventing cyst infection during EUS-guided aspiration of PCL and assess the rate of complications related to antibiotic use. METHODS: We included studies evaluating the outcomes of using PA in EUS-guided FNA of PCL. We searched PubMed, Embase, and Google Scholar through April 2019. Eligible studies were searched for variables of interest including infection of PCL and antibiotic-related complications. All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Relative risks (RR) with 95% confidence interval and heterogeneity was reported as I2 statistics. RESULTS: A total of 9 retrospective studies were eligible and included in the analysis. 6 studies compared the use of PA to no antibiotics while the other 3 did not have a comparison group. There were 1183 subjects in the antibiotic group and 579 subjects in the non-antibiotic group. Duration of antibiotics varied from a single intraprocedural dose to 3-5 days following the procedure. Multiple antibiotic regimens were used including ceftriaxone, quinolones, amoxicillin, and piperacillin/tazobactam. There was no statistically significant difference in the rate of cyst infection between patients receiving PA and those who did not (RR = 0.6, 0.21-1.75; I2 = 0%) (Figure 1). 1.2% of patients receiving PA developed adverse events related to antibiotic use. In addition, there was no difference among subgroups when stratifying subjects by single dose and 3-5 days of antibiotics (P = 0.619) (Figure 2). CONCLUSION: The incidence of infectious complications after EUS-guided FNA of PCL appears very low and the use of PA did not substantially reduce the risk. Antibiotic use is not free of adverse events. Further randomized controlled trials are needed to evaluate the appropriateness of current recommendations.

104 AGT Score as a Predictor of Common Bile Duct Stone Using Endoscopic Ultrasound (EUS) in Patients With Intermediate Probability Criteria According to ASGE Guidelines

INTRODUCTION: The performance of intermediate criteria guideline for the prediction of choledocholithiasis (CL) has been validated in very few studies. The objective of our study was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines intermediate criteria for the identification of CL. Furthermore, to identify the noninvasive predictors of CL. METHODS: A one-year prospective assessment of ASGE intermediate criteria was performed for the prediction of CL considering endoscopic retrograde cholangiopancreatography (ERCP) as gold standard test. Each patient underwent endoscopic ultrasound (EUS) prior to ERCP. Lab investigations were performed for all the patients and AGT score was calculated as a noninvasive predictor for CL. AGT score was calculated for each individual as. Sensitivity and specificity was calculated for predicting CBD stone by using AGT score. RESULTS: A total of 71 patients were suspected for choledocholithiasis according to ASGE intermediate probability criteria. The Mean age of patiens were 52.9 + 11.9 years and there were 42 (59.1%) males. At presentation, 66 (92.9%) had abdominal pain, five patients (7%) had gall stone pancreatitis and three (4.2%) had jaundice. On Endoscopic ultrasound (EUS), sludge was found to be in 7 patients (9.9%) and stones were reported in 43 (60.5%). On ERCP, 47 patients (66.2%) were found to have CL. Whereas, it was found in the study that TLC (8.11 vs 6.97 and P = 0.03), ALP (398 vs 197, P = 0.0001) and GGT (313 vs 215, P = 0.046) was significantly raised in stone positive group as compared to stone negative group. The product of Alkaline phosphatase (ALP) and GGT was also found to be significantly raised in stone positive group (130360 vs 57254 and P value 0.002). Using these variables AGT score was formulated and it was found to be significantly associated with presenct of CL (P = 0.001, 90222 vs 46746). Area under ROC of AGT score is 0.83. At a cut off value of 50069 the sensitivity, specificity, NPV and PPV were 82.9%, 76.1%, 88.64% and 66.6% respectively for AGT score in predicting choledocholithiasis. CONCLUSION: Performance of intermediate probability criteria for the prediction of CL was accurate in 66.2% of patients. Total bilirubin, gamma glutamyle transferase and AGT score was found to be the predictor of CBD stone.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment.

BACKGROUNDPost endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.AIMSTo study the published evidence and systematically review the literature on the prevention and treatment for PEP.METHODSA systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms “Post endoscopic retrograde cholangiopancreatography pancreatitis” AND “prevention” through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.RESULTS726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.CONCLUSIONPrevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.

Simethicone use during gastrointestinal endoscopy: Position statement of the Gastroenterological Society of Australia.

Concern has been raised regarding the use of simethicone, a de-foaming agent, during endoscopic procedures. Following reports of simethicone residue in endoscope channels despite high level disinfection, an endoscope manufacturer recommended that it not be used due to concerns of biofilm formation and a possible increased risk of microorganism transmission. However, a detailed mucosal assessment is essential in performing high-standard endoscopic procedures. This is impaired by bubbles within the gastrointestinal lumen. The Gastroenterological Society of Australia's Infection Control in Endoscopy Guidelines (ICEG) Committee conducted aliterature search utilizing the MEDLINE database. Further references were sourced from published paper bibliographies. Following a review of the available evidence, and drawing on extensive clinical experience, the multidisciplinary ICEG committee considered the risks and benefits of simethicone use in formulating four recommendations. Published reports have documented residual liquid or crystalline simethicone in endoscope channels after high level disinfection. There are no data confirming that simethicone can be cleared from channels by brushing. Multiple series report benefits of simethicone use during gastroscopy and colonoscopy in improving mucosal assessment, adenoma detection rate, and reducing procedure time. There are no published reports of adverse events related specifically to the use of simethicone, delivered either orally or via any endoscope channel. An assessment of the risks and benefits supports the continued use of simethicone during endoscopic procedures. Strict adherence to instrument reprocessing protocols is essential.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019.

ESGE recommends a low fiber diet on the day preceding colonoscopy.Strong recommendation, moderate quality evidence.ESGE recommends the use of enhanced instructions for bowel preparation.Strong recommendation, moderate quality evidence.ESGE suggests adding oral simethicone to bowel preparation.Weak recommendation, moderate quality evidence.ESGE recommends split-dose bowel preparation for elective colonoscopy.Strong recommendation, high quality evidence.ESGE recommends, for patients undergoing afternoon colonoscopy, a same-day bowel preparation as an acceptable alternative to split dosing.Strong recommendation, high quality evidence.ESGE recommends to start the last dose of bowel preparation within 5 hours of colonoscopy, and to complete it at least 2 hours before the beginning of the procedure.Strong recommendation, moderate quality evidence.ESGE recommends the use of high volume or low volume PEG-based regimens as well as that of non-PEG-based agents that have been clinically validated for routine bowel preparation. In patients at risk for hydroelectrolyte disturbances, the choice of laxative should be individualized.Strong recommendation, moderate quality evidence.

Abstract 4182: Community and cancer registry collaboration to reduce persistent stomach cancer disparity in Korean Americans: Asian American Stomach Cancer Task Force

Abstract South Korea and Japan have the highest stomach cancer incidence rates worldwide. Using 1988-2012 data from the California Cancer Registry, we have previously reported a striking stomach cancer disparity in Korean Americans, marked by 5 times higher incidence than in non-Hispanic whites (NHWs) and two times higher incidence than in Japanese Americans, the racial/ethnic group with the second highest incidence. The majority of Korean American adults were born in Korea while the majority of Japanese Americans adults were born in the US. Although Korean Americans had a more favorable stage distribution than other Californians in our earlier study, Korean Americans had a worse stage distribution compared to populations in Korea or Japan, where population-based screening is available. Data from South Korea demonstrated benefits of screening endoscopy in improving stage at diagnosis as well as mortality from stomach cancer. Bi-annual stomach cancer screening is now recommended for South Korean adults aged 40 or above, with an estimated participation rate of 75%. The United States lacks well-defined stomach cancer screening guidelines. In this study, we used the 2010-2014 Surveillance, Epidemiology, and End Results (SEER) data and compared stage distribution in Korean Americans in Los Angeles County, other areas in California, and SEER regions outside California. The proportion of early stage disease was highest in Korean Americans in Los Angeles County (49%), followed by other areas in California (41%) and SEER regions outside California (36%). The earlier diagnosis in Los Angeles County compared to other SEER regions was not observed for Japanese Americans or NHWs. It is reasonable to speculate that the increased public and physician awareness particularly in areas with a large Korean community helped Korean Americans somewhat overcome the disparity coming from the high incidence. However, the proportion of localized disease among Los Angeles County Korean Americans was still much lower than the proportion in Korea during the same time period (60-66%), indicating the need for targeted screening or well-defined guidelines for diagnostic endoscopy. Dissemination of these cancer registry findings led to a collaborative partnership between a number of Korean American community physician organizations and Los Angeles County SEER cancer registry, the Los Angeles Cancer Surveillance Program, establishing the ‘Asian American Stomach Cancer Task Force’ (AASCTF). The overarching goal of AASCTF is to reduce stomach cancer disparity in Korean Americans and other immigrants from high risk regions by promoting stomach endoscopy through community campaign and supporting research activities to help the medical community and policy makers to make evidence-based decisions. Citation Format: Eunjung Lee, Juanjuan Zhang, Sohee Park, Amie E. Hwang, Lihua Liu, Haeseong Park, Sang-Hoon Ahn, Anna H. Wu, Dennis Deapen. Community and cancer registry collaboration to reduce persistent stomach cancer disparity in Korean Americans: Asian American Stomach Cancer Task Force [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4182.

Development and validation of a web-based electronic application in managing antithrombotic agents in patients undergoing GI endoscopy

Antithrombotic therapy among patients undergoing GI procedures is frequently encountered and can impact the procedure and patient outcomes. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines help to manage these medications before endoscopy depending on the patient's clinical status and the type of GI procedure. However, currently there is no readily available electronic tool that can assist in decision-making regarding preprocedural management of these agents. Our aim was to develop an electronic application, endoscopy+ aid (ENDOAID), to help manage antithrombotic agents before endoscopy and to perform a validation study to test its accuracy. ENDOAID, a web-based application, was developed using JavaScript software (Oracle Corporation, Redwood Shores, Calif, USA) based on an algorithm to categorize patients and procedures into low and high risk as outlined in the updated ASGE guidelines published in 2016. Once pertinent information regarding a patient's clinical status and the procedure are entered, the application generates recommendations for the management of antithrombotic agents based on their cardiovascular risk and published ASGE guidelines. We performed a validation study with 52 patients who were referred to endoscopy and were taking antithrombotic agents. The patients were divided into groups of 5, and in the simulation each patient had 4 procedures. Different GI procedures were used in the simulation for each group of patients to ensure the entire spectrum of procedures were covered for analysis. Every simulation was then run through ENDOAID. The results from ENDOAID were compared with recommendations based on ASGE guidelines. The latter was derived by consensus between 2 endoscopists (the criterion standard). The personnel using the ENDOAID and those using the ASGE guidelines were different to avoid bias. Any clinical scenario that was unclear or not clearly outlined in ASGE guidelines was discussed with expert endoscopists for a final decision. We evaluated ASGE recommendations and calculated concordance rates between guidelines and ENDOAID results. The Pearson correlation coefficient (r) was calculated to assess the correlation between ENDOAID results to guidelines. There was a total of 208 simulated encounters, including 26 procedures. Initial concordance between ENDOAID recommendations and the criterion standard was seen in 206 encounters (99.03%). The 2 encounters that needed further review occurred among patients with Factor V Leiden mutation and deep vein thrombosis from antiphospholipid antibody syndrome and who were undergoing high-risk procedures that had ambiguous guidelines. ENDOAID suggested consultations with an expert before the elective procedure. This suggestion was agreed on by expert endoscopist consensus. Thus, ENDOAID showed a 100% concordance with the ASGE guideline for managing antithrombotics. There was a high degree of correlation (r= .996, P< .01) between ENDOAID results with ASGE. We have developed and validated an easy-to-use web-based application that can help in periprocedural management of antithrombotics. Such an application has the potential to simplify the management of these agents and potentially prevent procedural delays, cancellations, or unnecessary consults.

Implications of different guidelines for surveillance after serrated polyp resection in United States of America and Europe.

Because individuals with serrated polyps and adenomas are at increased risk of developing new polyps and colorectal cancer (CRC), surveillance after resection is justified. After adenoma resection, most international guidelines are consistent, but recommendations for surveillance after serrated polyp resection vary. The United States Multi-Society Taskforce on CRC (US-MSTF) base surveillance intervals on serrated polyp subtype (traditional serrated adenoma, sessile serrated polyp, hyperplastic polyps), while the European Society of Gastrointestinal Endoscopy (ESGE) guidelines do not take serrated polyp subtype into account. We evaluated the implications of this difference in a primary colonoscopy screening cohort. We included participants from a large colonoscopy screening trial. In a post-hoc simulation, assuming full protocol adherence, we determined the surveillance interval for each subject based on their polyp burden, using the most recent US-MSTF and ESGE guidelines. We included 5323 participants, of whom 1228 had one or more serrated polyps. In 5201 of all participants (98 %; Cohen's kappa 0.90) and in 1106 of those with serrated polyps (90 %; Cohen's kappa 0.80), both guidelines recommended identical surveillance intervals. Recommendations for a 3-year surveillance interval were identical between the two guidelines. All 122 subjects with discordant recommendations would receive a follow-up colonoscopy after 10 years using ESGE guidance and after 5 years using US-MSTF guidance. Despite the different criteria used to determine surveillance after serrated polyp resection, most individuals are recommended identical colonoscopy surveillance intervals whether following the ESGE or US-MSTF guidelines. This suggests that surveillance recommendations do not need to consider the serrated polyp subtype.

Mo1315 IS SUSPENDING HEPARIN-BASED ANTICOAGULATION NECESSARY PRIOR TO PERCUTANEOUS ENDOSCOPIC GASTROTOMY (PEG) PROCEDURE?

Percutaneous endoscopic gastrostomy (PEG) is considered a high-risk procedure and the current American Society of Gastrointestinal Endoscopy (ASGE) guidelines recommend withholding heparin-based anticoagulation, prior to PEG placement. Bleeding complications after PEG tube placement on uninterrupted heparin-based anticoagulation have not been previously studied. The aim of our study was to determine incidence of gastrointestinal bleeding (GIB) in patients undergoing PEG placement on uninterrupted heparin-based anticoagulation.

Improving patient safety in the endoscopy unit: utilization of remote video auditing to improve time-out compliance

Patient and procedure verification, or the time-out process (TOP), is considered one of the most vital components of patient safety. It has long been a focus of intervention in the surgical community and recently was incorporated into the American Society for Gastrointestinal Endoscopy guidelines for safety in the GI endoscopy unit. The TOP has had limited attention in the endoscopy literature but remains an area for improvement in clinical endoscopy practice. The aim of this study was to identify barriers and improve TOP compliance rates in our endoscopy unit using remote video auditing (RVA). This was a single-center, prospective, pilot initiative in an endoscopy unit at a tertiary care academic medical center. Video cameras with offsite monitoring were installed in each procedure room in our endoscopy suite in November 2016. Baseline TOP compliance rates were audited with RVA over a 2-month period. A multidisciplinary quality improvement team reviewed the data, identified barriers to the TOP, and implemented actionable items in January 2017. TOP compliance rates were again monitored via RVA, and data were collected through October 2018. Pre- and postintervention TOP compliance rates were compared. Over the baseline period, 692 procedures were audited and TOP compliance documented. Baseline TOP compliance rate was 69.6%. Identifiable barriers to TOP compliance included a lack of designated team member to lead TOP, inconsistent documentation of TOP, irrelevant safety checklist items not applicable to endoscopic procedures, and lack of patient safety culture. Actionable items implemented in response to these barriers included designation of a TOP leader, visual indication of initiation of TOP, creation of a concise endoscopy-specific safety checklist, and formal notification/education of the entire endoscopy team. Postintervention TOP compliance rates were then audited from January 2017 to October 2018 and included 12,008 procedures. The mean TOP compliance rate significantly improved from baseline (95.3% vs 69.6%; 95% confidence interval, 22.4-29.3; P< .0001). Additionally, the improvement was maintained throughout the entire postintervention observation period. TOP compliance rates significantly improved in our endoscopy unit through the use of RVA and implementation of 4 actionable items. Future studies should evaluate the reproducibility of this method in other endoscopy units.

Sa1004 – Undisclosed Payments by Pharmaceutical and Medical Device Manufacturers to Authors of Endoscopy Guidelines in the United States

Sa1004 – Undisclosed Payments by Pharmaceutical and Medical Device Manufacturers to Authors of Endoscopy Guidelines in the United States

Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.Strong recommendation, low quality evidence.ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.Strong recommendation, moderate quality evidence.ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:- severe, as soon as possible and within 12 hours for patients with septic shock- moderate, within 48 - 72 hours- mild, elective.Strong recommendation, low quality evidence.ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.Strong recommendation, moderate quality of evidence.ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence.ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.

Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study.

IntroductionExtensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India.MethodsThe study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed.ResultsASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively.ConclusionAccording to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018.

ESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence.ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome.Strong recommendation, low quality evidence.ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures.Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence.

Addressing acute gastrointestinal emergencies: From hemorrhage to obstruction

Background: Gastrointestinal bleeding (GIB) has traditionally been divided into upper and lower gastrointestinal bleeding (UGIB and LGIB). Advances in diagnostic technologies, including capsule endoscopy and balloon-assisted enteroscopy, have refined our understanding of small bowel bleeding, leading to a revised classification system encompassing upper, mid, and lower GIB. The rising incidence of LGIB is attributed to an aging population and increased antithrombotic use. Despite improvements in UGIB management, effective preventive strategies for LGIB remain insufficient, with significant hospitalization and mortality rates. Aim: This review aims to consolidate current knowledge on the initial management of acute LGIB, addressing advancements in predictive scoring systems, risk stratification, and the role of early colonoscopy. Methods: A comprehensive literature review was conducted, focusing on recent advancements and guidelines, including the 2016 American College of Gastroenterology guidelines for acute LGIB and the American Society for Gastrointestinal Endoscopy guidelines on antithrombotic management. Results: The review highlights the challenges in managing acute LGIB, including the diverse etiology of bleeding, the need for effective risk stratification tools, and the optimization of colonoscopy timing. New predictive models, such as the NOBLADS score and other risk scoring systems, provide valuable insights into severe LGIB outcomes.