Routine Endoscopic Procedures Research Articles

Carbapenem-resistant Enterobacterales sepsis following endoscopic retrograde cholangiopancreatography: risk factors for 30-day all-cause mortality and the development of a nomogram based on a retrospective cohort

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) has become a routine endoscopic procedure that is essential for diagnosing and managing various conditions, including gallstone extraction and the treatment of bile duct and pancreatic tumors. Despite its efficacy, post-ERCP infections – particularly those caused by carbapenem-resistant Enterobacterales (CRE) – present significant risks. These risks highlight the need for accurate predictive models to enhance postprocedural care, reduce the mortality risk associated with post-ERCP CRE sepsis, and improve patient outcomes in the context of increasing antibiotic resistance.ObjectiveThis study aimed to examine the risk factors for 30-day mortality in patients with CRE sepsis following ERCP and to develop a nomogram for accurately predicting 30-day mortality risk.MethodsData from 195 patients who experienced post-ERCP CRE sepsis between January 2010 and December 2022 were analyzed. Variable selection was optimized via the least absolute shrinkage and selection operator (LASSO) regression model. Multivariate logistic regression analysis was then employed to develop a predictive model, which was evaluated in terms of discrimination, calibration, and clinical utility. Internal validation was achieved through bootstrapping.ResultsThe nomogram included the following predictors: age > 80 years (hazard ratio [HR] 2.61), intensive care unit (ICU) admission within 90 days prior to ERCP (HR 2.64), hypoproteinemia (HR 4.55), quick Pitt bacteremia score ≥ 2 (HR 2.61), post-ERCP pancreatitis (HR 2.52), inappropriate empirical therapy (HR 3.48), delayed definitive therapy (HR 2.64), and short treatment duration (< 10 days) (HR 5.03). The model demonstrated strong discrimination and calibration.ConclusionsThis study identified significant risk factors associated with 30-day mortality in patients with post-ERCP CRE sepsis and developed a nomogram to accurately predict this risk. This tool enables healthcare practitioners to provide personalized risk assessments and promptly administer appropriate therapies against CRE, thereby reducing mortality rates.

Remimazolam for sedation in gastrointestinal endoscopy: A comprehensive review.

Worldwide, a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort. Propofol, benzodiazepines and opioids continue to be widely used. However, in recent years, Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal (GI) endoscopy. It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation. Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase, volume of distribution, total body clearance, and negligible drug-drug interactions. It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy. Furthermore, studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol, which is currently a gold standard for procedural sedation in most parts of the world. However, the use of Propofol is associated with hemodynamic instability and respiratory depression. In contrast, Remimazolam has lower incidence of these adverse effects intra-procedurally and hence, may provide a safer alternative to Propofol in procedural sedation. In this comprehensive narrative review, highlight the pharmacologic characteristics, efficacy, and safety of Remimazolam for procedural sedation. We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

S285 The Impact of the COVID-19 Pandemic on Endoscopy Procedure Volume and Cancer Detection Rate at a Large Academic Cancer Center

Introduction: The COVID-19 pandemic greatly affected the capacity to perform standard endoscopic procedures. Due to government mandate, practice shifted to performing only urgent procedures at the beginning of the pandemic followed by gradual resumption of elective procedures. We evaluated the impact of deferred colorectal cancer screening from March to December 2020 at a large academic cancer center. Methods: We performed a retrospective cohort study among adults aged 18 years and older who had an endoscopy procedure performed between January 2019 to December 2020 at the University of Texas MD Anderson Cancer Center. In March 2020, elective procedures were suspended, then resumed in June 2020, with close to full capacity achieved by September 2020. There was no suspension during the 2020 winter COVID-19 surge. Clinical data were obtained via extraction of electronic health records. Data were aggregated and analyzed by the Syntropy platform: Palantir Foundry (Foundry). Basic statistics were performed, including student’s t-test and Chi-squared analysis. Results: We identified 12444 endoscopy procedures performed on 9993 patients in 2019 and 9993 endoscopy procedures on 8138 patients in 2020 (Table 1). Between March and December 2020, 8756 COVID tests were performed pre-endoscopy, with an average positivity rate of 4.8%. In Texas, the average COVID positivity rate was 8.9%. Total endoscopy volume declined by 19.7% in 2020 compared to 2019 (P-value = 0.02). The sharpest declines in endoscopy were in April 2020, with EGD volume falling by 76%, colonoscopy volume by 78%, and ERCP volume by 16% compared to respective averages in April 2019. By the end of 2020, case volume returned to 2019 levels. From March 2020 to December 2020, 850 colonoscopies were cancelled; average adenoma detection rates (ADR) were 27.0 and average carcinoma detection rates (CDR) were 10.7, compared to ADR of 34.5 (P-value = 0.004) and CDR of 12.6 (P=0.71) for the same time period in 2019. See Figure 1. Conclusion: Total endoscopy volume declined by 19.7% in 2020 due to the impact of COVID-19 related changes in endoscopy practice. This impacted elective procedures such as screening colonoscopy procedures. The ADR was significantly lower in 2020 compared to 2019. There was not a significant change in CDR. These findings highlight the importance of increased routine endoscopic procedures, as the burden of COVID-19 diminishes.Table 1.: Demographic Characteristics of Patients Who Received Endoscopic Procedures in 2019 and 2020.Figure 1.: Endoscopic Procedures Performed and Adenoma and Carcinoma Detection Rates Over Time.

Low Risk of COVID-19 Infection in an Ambulatory Gastrointestinal Endoscopy Center in Argentina

Background and Objectives. Since the onset of the COVID-19 pandemic, concerns have been raised regarding the risk of infection to both healthcare staff and patients during gastrointestinal endoscopy procedures. Given the importance of performing routine endoscopic procedures to an individual’s future health, we sought to estimate the risk of COVID-19 infection for healthcare staff and patients undergoing endoscopic studies at an ambulatory endoscopy center during the pandemic. Material and Methods. This is a prospective(and) analytical cohort study conducted in an ambulatory gastroenterology center located in the Autonomous City of Buenos Aires, Argentina. Patients undergoing different endoscopic procedures were evaluated for COVID-19 between April 14 and August 31, 2020. COVID-19 was also evaluated in all healthcare and associated staff during the same time period. The risk (cumulative incidence) of acquiring COVID-19 in all patients and staff was calculated. Results. Between April 14 and August 31, 2020, procedures were performed in 3,745 patients with a mean age of 51.12 years; 2,102 (56.18%) were male and 1,643 (43.82%) were female. Follow-up was completed in 3,492 patients, 18 of whom tested positive for COVID-19 standing for an incidence of 0.52% (95%CI 0.31 – 0.81%). Six (5.45%) out of 110 staff members were infected with COVID-19 (1 endoscopist, 4 endoscopy assistants and 1 administrative staff member). In this group, the incidence of positive tests for COVID-19 was 5.45% (95%CI: 2.03 – 11.50%). The increased rates of positive cases among our patients and healthcare professionals were respectively 7.9 and 23.6 times lower than in general population. Conclusion. During the study period, the proportion of COVID-19 infections in our ambulatory specialized in gastrointestinal endoscopy was low and much lower than that in the general population for both patients and healthcare professionals. Endoscopic procedures undertaken at this center were low risk, likely due to strict compliance with established pandemic protocols. Future studies should compare the risk of infection in the hospital setting.

P079 Valproic acid increases MiR449a expression in intestinal mucosa from patients with inflammatory bowel disease

Abstract Background Histone acetylation/deacetylation and microRNAs (MiRNA) are epigenetic mechanisms involved in the pathogenesis of inflammatory bowel diseases (IBD). Histone deacetylase (HDAC) inhibitors, such as valproic acid (VPA), demonstrated anti-inflammatory and anti-tumour effects in animal models of colitis.1,2 Modulation of MiRNAs is hypothesized to be a possible mechanism of action of HDAC inhibition.3 Recently, VPA was shown to modulate histone-3 (H3) acetylation and cytokine production in the human gut.4 In this study, we analysed whether VPA influences MiRNA expression in ex-vivo biopsies from IBD patients. Methods Colonic biopsies from IBD patients collected during routine endoscopic procedures were cultured with VPA (5 mM) or control media for 24 hours. Total RNA was extracted and a MiRNA array was performed (miScript™ miRNA PCR Array), profiling the expression of 84 MiRNAs predicted to regulate pro- or anti-inflammatory genes. Significantly altered MiRNAs were then validated in an independent cohort of samples using quantitative (q) RT-PCR. Caco-2 (ATCC® HTB-37™) cell cultures treated with VPA (5 mM) or control media were used to confirm changes of H3 acetylation and MiRNA expression. After 24 hours, H3 acetylation was evaluated by immunofluorescence and apoptotic markers were analysed by qPCR. Results Colonic biopsies from inflamed mucosa of 6 IBD patients (2 with Crohn’s disease (CD) and 4 with ulcerative colitis (UC)) were cultured with VPA or control media. MiRNA analysis showed a significant increase of miR449a, miR373-3p, miR300 and miR520d-3p in treated biopsies compared to control (p=0.004, p=0.024, p=0.04 and p=0.014, respectively). Validation was performed in an independent cohort of 14 IBD patients (7 CD; 7 UC), confirming a significant increase of MiR449a (p=0.026) in VPA treated biopsies. VPA treated Caco-2 cell cultures showed a significant increase of H3 acetylation density level (p=0.02), confirming the HDAC inhibitory activity. Gene expression analysis showed increased Caspase-3 (p=0.015), a pro-apoptotic marker, and decreased BCL-3 (p&amp;lt;0.01), an anti-apoptotic marker. The level of MiR449a expression in VPA treated cells was significantly elevated (p&amp;lt;0.01). Conclusion VPA increases the expression of MiR449a in cultured ex-vivo biopsies and in Caco-2 cells. This MiRNA has recently demonstrated to be involved in IBD pathogenesis and in colitis-associated colon cancer. This may represent a new insight into IBD pathogenesis and colitis-associated colon cancer development. Further work is required to determine the functional significance of miR-499a in the human intestine. References

Screening for hepatitis C in an outpatient endoscopy unit.

The Canadian Liver Foundation recommends routine hepatitis C (HCV) screening for Canadians born between 1945 and 1975. This study aimed to determine the feasibility and outcomes of targeted birth cohort HCV screening during routine outpatient endoscopic procedures in a tertiary care hospital. We conducted a prospective cohort study of individuals born between 1945 and 1975 who attended outpatient endoscopy procedures at Kingston Health Sciences Centre from 2017 to 2019. Patients who consented received the HCV OraSure point-of-care test for the HCV antibody (HCV Ab). If positive, serum for HCV RNA was sent, and patients were linked to care with a hepatologist. 2,179 patients met birth cohort criteria for HCV screening. Of those, 1,079 (49.5%) were approached for study inclusion, and 160 (15.0%) declined participation, leaving 912 patients who provided consent. The median age was 62 years (IQR 55-67). Overall, 6/912 (0.7%) of participants were HCV Ab positive and 5/912 (0.6%) were HCV RNA positive. Four were linked to care for consideration of direct-acting antiviral (DAA) therapy, 3 received DAA treatment, and all 3 achieved sustained virologic response (SVR). Birth cohort screening for HCV in an outpatient endoscopy unit identified an HCV prevalence similar to population estimates. In this model, however, 50% of eligible patients were not approached for screening. Linkage to care for assessment of treatment was high at 80%, and of those who received therapy, all achieved SVR. These results suggest this cohort is a suitable population for HCV screening; however, we need strategies to increase recruitment of all eligible individuals.

S0524 Safety Profile of Endoscopist-Directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-Based Endoscopy Unit

INTRODUCTION: Nurse administered propofol sedation was widely used for endoscopic procedures until 2009 when its use was restricted to anesthesiologists per CMS guidelines, a practice that has led to increases in healthcare costs. Aim was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS) for endoscopy. METHODS: We identified patients who underwent endoscopic procedures with EDBPS from Jan to Jun 2017. Medical records were abstracted for data on procedure indication, medication doses, time to induction of sedation, duration of procedure and recovery time. Adverse events (AEs) included: Hypoxia - oxygen saturation (SPO₂) 50 mm Hg, c) Drop in mean arterial pressure (MAP) > 30%; Bradycardia (heart rate < 40 beats/minute). Major complications include death, neurologic sequelae (CVA, permanent cognitive impairment), and need for hospitalization or endotracheal intubation. RESULTS: A total of 1897 patients received EDBPS during the study period. Mean age was 55 (SD 11.4) years and 43.6% were men. Patients received median doses of 50 mcg fentanyl and 2 mg of midazolam and a mean propofol dose of 160 ± 99 mg (range 20–960). Mean time for sedation induction was 3.4 (SD 1.9) and mean recovery was 14 (SD 10.2) min. There were no major complications (0%; 95% CI, 0–0.19%). Three hundred thirty-four patients (17.6%) experienced an AE, all of which were managed with simple measures (chin-lift, jaw thrust and increasing flow of O₂ and IV fluids): 65 (3.4%) had transient hypoxia, 277 (14.6%) had hypotension. In bivariate analysis, a 5-yr increase in patient age was associated with in increased risk of hypotension. A 50 mg increase in propofol dose was associated with a statistically significant risk of transient hypoxia. A 10-min increase in procedure duration was associated with statistically significant risk of both transient hypoxia and hypotension (Table 1). Age, weight, BMI, propofol dose and procedure length were associated with AEs (Table 2). Gender had no association with AEs. In multivariate analysis, only procedure length was independently associated with AEs. CONCLUSION: EDBPS is safe for endoscopic procedural sedation, as AEs occurred infrequently. Given the much higher cost of anesthesia-administered propofol for routine endoscopic procedures, endoscopists should re-instate EDBPS by revising institutional sedation policies.Table 1Table 2

A New Solution for Routine Endoscopic Aerosol-Generating Procedures (AGPs) in the COVID-19 Pandemic.

There is urgent need to find a swift and cheap way to safely perform routine endoscopic procedures during the otolaryngological and anesthesiological practice. We want to share our experience of a novel device, inspired by the pediatric head box experience. Five otolaryngologists and four anesthesiologists were asked to visualize the glottic plane by using the device. A total of 15 attempts was allowed to reach the vocal folds within 60 seconds after entering the box. Student's t-test for unpaired samples was used to compare groups. Transnasal laryngoscopy through our endobox could be successfully performed by all the physicians involved and the mean number of attempts before visualizing and passing the glottis for the first time was 2.8 (range 1-5) in the otolaryngologists' group versus 3.2 (range 1-6) in the anesthesiologists' group (P=0.583). Out of the 15 attempts, the group of otolaryngologists reached the glottis 10.2 times, on average, against 9.7 in the other group (P=0.692). Our endobox seems a practical and feasible strategy to control droplets diffusion during standard ear, nose, and throat and anesthesiological practice.

Etiology and Comorbidity Diagnoses Effect on Outcomes for Patients Undergoing Endoscopic Retrograde Cholangiopancreatography.

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) is now the first-line approach to treating choledocholithiasis. As a minimally invasive procedure, it is considered relatively safe but still entails a higher risk than other routine endoscopic procedures. This study aims to look at possible patient etiologies and comorbidities that may affect patient outcomes. MethodsThis study used the Nationwide Inpatient Sample (NIS) from the years 2012 - 2015 to collect anonymous patient data through the use of International Classification of Diseases, Ninth Revision (ICD-9) codes. Specific codes were used to determine the top five etiologies (or presenting diagnosis) for patients who had this surgery and to separate outpatients with specific comorbidity diagnoses. The IBM Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY) was then used to compare patients with these diagnoses or etiologies to those without to measure differences in patient outcomes, such as mortality, length of stay, and total charges.ResultsPatients who had an etiological diagnosis of acute kidney failure had worse outcomes than patients who were admitted for ERCP without that etiological diagnosis. There were also specific comorbidity diagnoses that were noted to have worse patient outcomes, including congestive heart failure, diabetes mellitus with complications, a coagulopathy disorder, anemia, or chronic liver disease. Additionally, patients who had both acute kidney disease and chronic liver disease had the worst outcomes.ConclusionsThis study highlights the need to understand all patient risk factors before having them undergo ERCP, especially in the setting of scheduled surgery. Working to control these factors before surgery can increase the possibility of avoiding negative outcomes like mortality, increased patient costs, and increased length of stay.

ENT endoscopic procedures and aerosolization during COVID-19 pandemic: a review of concepts and guidelines

&lt;p class="abstract"&gt;Otolaryngologists are more prone for exposure to aerosols during routine ENT examination and endoscopic procedures. ENT endoscopy procedures are considered as most aerosol-generating procedures and preferably routine procedures are avoided and deferred, if at all not necessary or urgent at this time of COVID-19 pandemic. The small particle size and extended travel of airborne aerosols mandate the use of specific personal protective equipment (PPE) and barriers by the health care workers to protect against transmission of COVID-19. Studies have recommended ENT endoscopy in awake patients with adequate topical preparation for local anaesthesia. Use of sprays should be avoided, instead, carefully placed pledgets should be used to provide adequate decongestion and anesthesia. Well ventilated endoscopy room with negative pressure (preferably), wearing a N95 mask with face shield or full PPE, thorough cleaning of entire endoscope after removal by standard disinfectants, decontamination of endoscopy room after each procedure and proper disposal of contaminated waste products are some common guidelines advised by health authorities globally till date.&lt;/p&gt;

COVID-19 pandemic through the lens of a gastroenterology fellow: looking for the silver lining

COVID-19 pandemic through the lens of a gastroenterology fellow: looking for the silver lining

A148 EFFICIENCY IN THE ENDOSCOPY UNIT: CAN WE ‘TURN AROUND’ ROOM TURNOVER?

Abstract Background Endoscopy units across Canada are being challenged to meet the growing demand for procedures despite limited resources, highlighting the need to optimize endoscopy unit efficiency. Earlier studies have found that non-procedural factors, such as room turnover, represent an ideal target to improve efficiency. Aims The objective of this research project was to identify practices that will improve efficiency for routine outpatient gastrointestinal (GI) procedures at Sunnybrook Health Sciences Centre (SHSC). There were 2 sub-aims: 1) to understand practices at Toronto hospitals that shorten room turnover time and 2) to describe the variation in room turnover time at SHSC. Methods Sub-aim #1: A survey of endoscopy units at five other Toronto hospitals was completed. Questions were designed to gain a better understanding of routine practices and any initiatives undertaken to improve room turnover efficiency. Sub-aim #2: Median room turnover time from April 2018 to March 2019, defined as ‘patient out’ to ‘patient in’, was reported in an anonymized fashion for the following categories: 1) by endoscopist, 2) by nurse, and 3) by unique endoscopist-nurse pair. Only data from routine outpatient endoscopic procedures (e.g. colonoscopy, gastroscopy, flexible sigmoidoscopy) were included. In order to evaluate turnover times by endoscopist-nurse pair, consecutive cases not performed by the same pair were excluded. Procedures affected by patient- and transportation-related delays were also excluded. Results Of the five centers surveyed, three allocated 5 minutes for turnover and two allocated 10 minutes. All centers reported tracking turnover time and four centers reported undertaking initiatives to decrease turnover time such as involving a flow team, hiring team attendants, and sharing performance data. Over the 12-month period, 2504 routine outpatient GI endoscopic procedures were performed at SHSC, with 803 cases meeting inclusion criteria. Median turnover time for the unit was 6 minutes, ranging from 5 to 9 minutes across endoscopists, 5 to 7 minutes across nurses, and 3 to 10 minutes across unique endoscopist-nurse pairs (Figure 1). Efficiency of endoscopist-nurse pairs did not correlate with the number of cases performed as a pair over the 12-month period. Conclusions Endoscopy room turnover times at SHSC are similar to those reported by other local centers, with important variation across endoscopists and nurses. The next phase of this study will involve directly observing each of the most and least efficient individuals and pairs and recording common practices. It is anticipated that these findings will enable us to identify efficient practices that should be incorporated into standard operating procedures and training for endoscopy room personnel. Funding Agencies None

Healthcare for non-Covid-19 liver disease patients during the Covid-19 pandemic in Bangladesh: Current trend and future implications.

Healthcare for non-Covid-19 liver disease patients during the Covid-19 pandemic in Bangladesh: Current trend and future implications.

The rise, fall, and future direction of computer-assisted personalized sedation.

The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

Digital recording and documentation of endoscopic procedures: physicians\u2019 practice and perspectives

BackgroundIn recent years, it has become increasingly prevalent internationally to record and archive digital recordings of endoscopic procedures. This emerging documentation tool raises weighty educational, ethical and legal issues – which are viewed as both deterrents and incentives to its adoption. We conducted a survey study aimed at evaluating the use of DRD in endoscopic procedures, to examine physicians’ support of this practice and to map the considerations weighed by physicians when deciding whether or not to support a more extensive use of DRD.MethodsIsraeli physicians from specialties that employ endoscopic technics were surveyed anonymously for demographic background, existence and use of recording equipment, existence of institutional guidelines regarding DRD, and self-ranking (on a scale from 1 to 7) of personal attitudes regarding DRD.Results322 physicians were surveyed. 84% reported performing routine endoscopic procedures, 78% had the required equipment for digital recording, and 64% of them stated that they never or only rarely actually recorded the procedure. General surgeons had the second highest rate of DRD equipment (96.5%) but the lowest rates of DRD practice (17.5%). The average ranking of support of DRD by all participants was 5.07 ± 1.9, indicating a moderately high level of support. Significant positive correlation exists between actual DRD rates and average support of DRD (p < 0.001). Based on mediation models, for all specialties and with no exceptions, having routine recording guidelines and positive support of DRD were found to increase the probability of actual recording. Being a surgeon or an urologist negatively correlated with support of DRD, and decreased actual recording rates. The argument “Recording might cause more lawsuits” was ranked significantly higher than all other arguments against DRD (p < 0.001), and “Recording could aid teaching of interns” was ranked higher than all other arguments in favor of DRD (p < 0.001).ConclusionsWhile DRD facilities and equipment are fairly widespread in Israel, the actual recording rate is generally low and varies among specialties. Having institutional guidelines requiring routine recording and a positive personal support of DRD correlated with actual DRD rates, with general surgeons being markedly less supportive of DRD and having the lowest actual recording rates. Physicians in all specialties were very much concerned about DRD’s potential to enhance lawsuits, and this greatly influenced their use of DRD.These findings should be addressed by educational efforts, centering on professionals from reluctant specialties, as well as by the issuing of both professional and institutional guidelines endorsing DRD as well as requiring it where applicable.

Tu1093 FAILED CONSCIOUS SEDATION AND IMPACT ON ADENOMA DETECTION RATES

Conscious sedation (CS) and monitored anesthesia care (MAC) are the primary means of providing sedation for routine endoscopic procedures in the United States. Approaches vary between institutions and regionally, without clear guidelines to guide type of sedation used. Physicians rely on patient history and health status to help triage appropriately, but CS failures arise. We sought to study the predictors of CS failure and whether this affects the adenoma detection rate (ADR).

Streptococcus bovis Endocarditis after Colonic Polypectomy.

We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation. Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up.This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis.LEARNING POINTSInfective endocarditis occurring in association with gastrointestinal endoscopy is rare.Clinical suspicion of infective endocarditis after colonic polypectomy or biopsy should be maintained, especially in those with risk factors for infective endocarditis.Antibiotic prophylaxis against infective endocarditis is not recommended for routine gastrointestinal endoscopic procedures.

Primary application of progressive teaching on endoscopic ultrasonography training program

Objective To compare the effect of progressive teaching pattern with traditional long-term training on improvement of trainees ability of endoscopic ultrasonography (EUS). Methods Ten learners who have achieved competence on routine endoscopic procedures but without any knowledge and skills on EUS procedures were enrolled in the study, and were randomly divided into two groups according to the sequence number. Learners with odd number received traditional long-term training, and the even number learners received progressive teaching. The proficiency of EUS knowledge and skills in the two groups were compared after one-year learning. Results At the final examination, the learners′ ability of mastering EUS was higher, and the study leave time was shorter in the progressive teaching group than that in the traditional long-term training group. however, we didn′t have a statistical comparison owing to the few numbers of trainees. Conclusion Progressive teaching pattern is superior to the traditional training, and it should be advocated when hospitals are relatively understaffed. Key words: Endosonography; Training program; Progressive teaching

Nonoperating room anesthesia for gastrointestinal endoscopic procedures.

To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Multispectral light scattering endoscopic imaging of esophageal precancer

Esophageal adenocarcinoma is the most rapidly growing cancer in America. Although the prognosis after diagnosis is unfavorable, the chance of a successful outcome increases tremendously if detected early while the lesion is still dysplastic. Unfortunately, the present standard-of-care, endoscopic surveillance, has major limitations, since dysplasia is invisible, often focal, and systematic biopsies typically sample less than one percent of the esophageal lining and therefore easily miss malignancies. To solve this problem we developed a multispectral light scattering endoscopic imaging system. It surveys the entire esophageal lining and accurately detects subcellular dysplastic changes. The system combines light scattering spectroscopy, which detects and identifies invisible dysplastic sites by analyzing light scattered from epithelial cells, with rapid scanning of the entire esophageal lining using a collimated broadband light beam delivered by an endoscopically compatible fiber optic probe. Here we report the results of the first comprehensive multispectral imaging study, conducted as part of routine endoscopic procedures performed on patients with suspected dysplasia. In a double-blind study that characterized the system’s ability to serve as a screening tool, 55 out of 57 patients were diagnosed correctly. In addition, a smaller double-blind comparison of the multispectral data in 24 patients with subsequent pathology at locations where 411 biopsies were collected yielded an accuracy of 90% in detecting individual locations of dysplasia, demonstrating the capability of this method to serve as a guide for biopsy.