Therapeutic Endoscopic Procedures Research Articles

Upcoming Italian clinical practice guidelines on endoscopic bariatric treatment of overweight and obesity: design and methodological aspects.

Obesity/overweight and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to develop the first Italian guidelines for the endoscopic bariatric treatment of obesity. The creation of SICOB Guidelines is based on an extended work made by a panel of 44 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (patient, intervention, comparison, outcome) conceptual framework. We will perform systematic reviews, formal meta-analyses, and network meta-analyses for each PICO and critical outcomes aimed at assessing and rating the efficacy and safety of endoscopic bariatric procedures in comparison with either no interventions, lifestyle interventions, or approved anti-obesity treatments in trials with a follow-up of at least 52 weeks. For PICO on temporary endoscopic bariatric treatments, we will also consider RCT with a minimum duration of 6 months. The panel proposed 8 questions, organized into four domains: A. Indication for endoscopic bariatric surgery; B. Revisional surgery; C. Temporary gastric and duodenal-jejunal procedures; D. Endoscopic diagnosis/treatment of bariatric and metabolic surgery complications. These guidelines will apply to patients aged ≥ 14 years) with body mass index (BMI) ≥ 27 kg/m2 and requiring endoscopic bariatric surgery or endoscopic diagnostic and/or therapeutic procedures. The areas covered by the clinical questions included indications of endoscopic bariatric surgery, types of surgery, revisional surgery, and management of bariatric and metabolic surgery complications.

Intraduodenal and retroperitoneal hematoma after duodenal biopsies

Abstract We present the case of a 20-year-old male with no previous history of interest who developed an intraduodenal and retroperitoneal hematoma in the context of an oral endoscopy with duodenal biopsies due to abdominal pain and chronic diarrhea. The evolution with conservative treatment was favorable and ultrasound controls were performed until resolution. Intraduodenal hematomas are lesions that are usually observed in children after blunt abdominal trauma or in patients with risk factors, being infrequent as a complication after diagnostic or therapeutic endoscopic procedures. Their management is mainly conservative and in case of absence of improvement or perforation, surgery is indicated.

Rotational Thromboelastometry Reduces Fresh Frozen Plasma Requirement in Patients without Liver Disease Undergoing Therapeutic Endoscopic Procedures with Deranged Screening Coagulation Tests—A Pilot Study

Abstract Background/Aims Rotational thromboelastometry (ROTEM) is a viscoelastic test that is used in patients with liver disease for guiding blood component use. This study is aimed at comparing the amount of blood products transfused and bleeding rates in patients without liver disease, who underwent therapeutic endoscopic procedures with deranged screening coagulation tests (prothrombin time [PT]; activated partial thromboplastin time [aPTT]), with and without hypocoagulable ROTEM. Methods Patients with deranged PT and aPTT without liver disease who underwent therapeutic endoscopic interventions during the period 2020 to 2022 were retrospectively analyzed. Baseline parameters, amount of blood products transfused, and outcomes such as 30-day bleeding and mortality rates were recorded in those with and without hypocoagulable ROTEM. Results Of the 204 patients with deranged PT/aPTT who underwent therapeutic endoscopy during the study period, 180 of those with liver disease were excluded. Six patients (M:F = 5:1; median age: 37, 20–54 years) had hypocoagulable ROTEM and 18 patients (M:F = 11:7; median age: 56, 20–71 years) had normo-/hypercoagulable ROTEM. There were significant differences in the total amount of fresh frozen plasma (FFP) transfused and FFP transfused per patient between the two groups (9,000 vs. 4,500 mL and 2,000 vs. 1,000 mL; p = 0.04, respectively). Two patients with hypocoagulable ROTEM bled within 30 days, while none did in the comparator group (p = 0.03). One patient in the hypocoagulable group died within 30 days and none in the normo-/hypercoagulable group. Conclusion The use of ROTEM reduces FFP requirement in patients without liver disease with deranged PT/aPTT undergoing therapeutic endoscopic procedures without any increased risk of early or late rebleeding, and 30-day mortality.

Pediatric Therapeutic Endoscopic Procedures Performed by Adult Trained Advanced Endoscopists Are Safe and Effective

Pediatric Therapeutic Endoscopic Procedures Performed by Adult Trained Advanced Endoscopists Are Safe and Effective

Influence of Frailty in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Biliary Stone Disease: A Nationwide Study.

Pancreaticobiliary diseases are common in the elderly. To this end, frailty represents a state of vulnerability that should be considered when assessing the risks and benefits of therapeutic endoscopic procedures. We aim to determine the rate of readmissions and clinical outcomes using the validated Hospital Frailty Risk Score in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Using the National Readmissions Database, we identified patients with an admission diagnosis of cholangitis with obstructive stone from 2016 to 2019. Patients were determined to be of low frailty risk with a score of < 5, while patients of medium to high frailty risk had a score of > 5. During the study period, 5751 patients were identified with acute cholangitis with obstructing stone. Mean age of index admissions was 69.4years and 51.8% were female. From the total cohort, 5119 (89.2%) patients underwent therapeutic ERCP, 38.0% (n = 1947) of whom were regarded as frail (risk score > 5). Following ERCP, frail patients had a less but statistically insignificant readmission rate compared to non-frail patients (2.76% vs 4.05%, p = 0.450). However, compared to non-frail patients, frail patients experienced higher post-ERCP complications (6.20% vs 14.63%, p < 0.001). Frail patients were more likely to have longer lengths of stay, higher hospital cost, and mortality risk. ERCP is not a risk factor for readmission among frail patients. However, frail patients are at higher risk for procedure-related complications, healthcare utilization, and mortality.

Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy.

Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.

Repair of Bowel Perforation: Endoscopic State of the Art

Background: Intestinal damage from various etiologies can result in the potentially dangerous complication of bowel perforation. Emergent treatment of small bowel perforation includes surgical repair with or without small bowel resection. As the number of therapeutic and diagnostic endoscopic procedures increase, more studies may be required to properly evaluate and report incidences of bowel perforation. Given the advantages of interventional procedures, novel endoscopic technologies which may prove beneficial in bowel perforation repair are continuously undergoing development. Bowel perforation can lead to peritonitis and sepsis – a medical emergency requiring immediate attention. Following diagnosis, hemodynamically stable patients may be treated conservatively whereas unstable patients undergo more intensive surgical procedures. Endoscopic procedures for bowel perforation repair also exist and recent advances in technology are furthering the scope of such closure methods. Methods and Findings: Endoscopic suturing technologies, while capable, require extensive training and entail prolonged activation processes. Wound vacuum sponge closure via endoscopy provides convergence of wound defects but may not be efficacious in defects larger than 5 cm. Furthermore, this method may be limited by inadequate seal and placement in the intestine. Endoscopic clipping is another modality beneficial for smaller perforations only. T-tag suturing has shown promising results in ex-vivo studies but entails blind placement of T-tags for perforation closure. Stents can be inserted endoscopically under fluoroscopic visual guidance. This technique, however, may result in stent migration, perforations and potential occlusions. Sealants can be injected for perforation closure but have not demonstrated clear efficacy. Robotic flexible endoscopy provides several novel features yet may require advanced training and sometimes more than one operator. As interventional procedures continue to gain popularity, a better understanding of endoscopic modalities is helpful for furthering their development. Regarding bowel perforation, this review aids in an overall understanding of the technologies which exist and are advancing further into more standard modalities for practical medical applications. Conclusion: There are currently various methods to repair perforation of the gastrointestinal wall and except for urgent exploratory laparotomy when indicated, there is likely no single method that is superior to others. It may be beneficial for the physician to consider all options for repair when evaluating a potential bowel perforation, considering physician preference and individual success or difficulty with a given modality. In more recent years as the focus has narrowed on minimally invasive procedures, future modalities will likely include increased automation and ease of use with the help of robotics, which will hopefully lead to decreased time to diagnosis, faster recovery and reduced morbidity and mortality.

Electrical equivalent model of a long dielectric barrier discharge plasma jet for endoscopy

Cold atmospheric plasmas are a known source of reactive species enabling various treatments, from the healing of chronic wounds to the treatment of surface cancers. Therapeutic endoscopic procedures require developing specific flexible tools that can be used through or alongside endoscopes. Plasma devices for endoscopy have aroused significant research interest over the past few decades, but their electrical behaviour is not yet fully understood and predictable. There is thus a clear need for a robust model that provides a way to understand and optimize future devices. In this work, for the first time, an electrical equivalent model of a long plasma source (comprising plasma generation, transport and target interaction) was designed, implemented, and validated. System parameters were estimated based on the system geometry and independent measurements. The model reliably reproduces the double ignition (in the quartz chamber and at the treatment site) observed experimentally. Simulations globally agree with measurements taken for various gas gap distances and input voltages. Internal parameters that are difficult to measure, such as the electrical charge at the gas gaps, were inferred. The model can predict leakage current in the body and current at the target site. This work provides a new understanding of endoscopic plasma systems that could be used in the future to ensure patient and operator safety.

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.

Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience.

We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives.

Background and study aims Therapeutic EUS (t-EUS) is increasingly being adopted in clinical practice in tertiary referral centers; however, little is known about radiation exposure (RE) metrics and diagnostic reference limits for it. Methods Kerma-area product (KAP [Gy·cm 2 ]), Air Kerma and fluoroscopy time were retrospectively evaluated for all consecutive t-EUS procedures performed in San Raffaele Institute between 2019 and 2021. For EUS-guided choledochoduodenostomies (EUS-CDS) and gastroenterostomies (EUS-GE), an equal number of endoscopic retrograde cholangiopancreatographies (ERCPs) plus metal stenting and duodenal stents were included respectively for comparison. Results Data from 141 t-EUS procedures were retrieved (49 % pancreatic cancer, 38 % peripancreatic fluid collections). EUS-CDS (N = 44) were mainly performed fluoroless, while ERCPs required a significantly higher RE (KAP = 25 [17–55], P < 0.0001). Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 [13–45]). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3–21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 [28–88] versus 29 [19–46], P = 0.03). EUS-guided hepaticogastrostomies (EUS-HGS, N = 10) had the highest RE among t-EUS procedures (KAP = 81 [49–123]). Procedure complexity or intervening complications were evaluated and resulted in higher RE within each procedure. Conclusions t-EUS procedures have different RE ( P < 0.000001). EUS-CDS, EUS-GBD, and EUS-FCD with LAMS can be performed with no-to-mild radioscopy, unlike standard alternatives. However, radioscopy remains essential in case of technical difficulties or complications. EUS-GE and EUS-HGS involve a high RE. Endoscopists involved in t-EUS might experience RE higher than category standards, which indicates a need for increased awareness and personalized preventive measures.

Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study.

Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures. This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO2 concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient. Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24-9.78], P=0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3min before hypoxic events. Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.

Bronchoscopy in COVID-19 inpatients: experience of a university hospital in the first outbreak of the disease in Brazil.

ABSTRACTObjective:To describe the indications and endoscopic findings of bronchoscopy performed at a reference university hospital for inpatients diagnosed with COVID-19 during the first outbreak of the disease in Brazil.Methods:A retrospective analysis of medical records of adult patients diagnosed with COVID-19 who underwent bronchoscopy at the intensive care units of Instituto do Coração and Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, from March to August 2020.Results:A total of 132 bronchoscopies were performed in 103 patients diagnosed with COVID-19. Mean age was 56.1±14.5 years, and distribution was similar in both sexes. More than one test was performed in 16 patients. The most frequent indications were diagnostic endoscopic evaluation and therapeutic procedures in 78.6% of cases (n=81) and material collection in 21.4% of cases (n=22). The most frequent endoscopic findings were presence of secretion or clots in 34% of cases, the presence of acute inflammatory changes in 22.3%, and tracheal wall laceration in 20.4%. In 27.2% of patients, no relevant bronchoscopic findings were observed. In three patients, bronchoscopy was indicated to assess hemoptysis, but there was only one case of active bleeding. Procedure-related complications were not observed in this group of patients.Conclusion:Bronchoscopy proved to be a safe and effective procedure to assist in treatment of COVID-19 patients, and the most frequent indications were related to investigation of airway involvement or to evaluate infectious and inflammatory pulmonary processes.

A 3D-printed innovative pedal fixator for connecting different pedal-operated tools to improve work ergonomics during advanced diagnostic and therapeutic endoscopic procedures.

A 3D-printed innovative pedal fixator for connecting different pedal-operated tools to improve work ergonomics during advanced diagnostic and therapeutic endoscopic procedures.

Analysis of the effects of the first and second/third waves of the COVID-19 pandemic on an Interdisciplinary Endoscopy Unit in a German 'hotspot' area: a single-center experience.

Background:Since December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed a pandemic threat to global health. We are now in the fourth wave of this pandemic. As the pandemic developed, the requirements and therapeutic endoscopic procedures for SARS-CoV-2-positive patients underwent changes.Methods:Analysis of implications for an endoscopy unit during the first and second/third waves of the COVID-19 pandemic with a focus on COVID-19-related process changing. Addressed are number of SARS-CoV-2-positive patients and endoscopic examinations performed in patients who tested positive for SARS-CoV-2 during the various waves, adherence to scheduled examinations, rotation of staff to COVID-dedicated structures and, finally, impact of vaccination on infection rate among endoscopic staff.Results:During the first wave, 10 SARS-CoV-2-positive in-house patients underwent a total of 22 gastrointestinal (GI) endoscopic procedures. During the second and third waves, 59 GI endoscopies were performed in 38 patients. While in the first wave, GI bleeding was the main indication for endoscopy (82%), in the second and third waves the main indication for endoscopy was endoscopic insertion of deep feeding tubes (78%; p < 0.001). During the first wave, 5 (17%) of 29 Interdisciplinary Endoscopy Unit (IEU) staff members were moved to designated COVID wards, which was not necessary during the following waves. Lack of protective clothing was critical during the first wave, but not in the later waves. Screening tests for patients and staff were widely available after the first wave, and IEU staff was vaccinated during the second wave.Conclusion:Strategies to ensure safe endoscopies with respect to preventing transmission of SARS-CoV-2 from patients to staff were effective. Organizational adjustments allowed the routine program to continue unaffected. Indications for GI endoscopies changed over time: during the first wave, GI endoscopies were performed for life-threatening indications, whereas later supportive procedures were the main indication.

Gastrointestinal Endoscopy Practice in Pandemic Conditions

Objective A novel coronavirus, which is termed COVID-19 or SARS-CoV-2, was declared a pandemic by the WHO since March 2020. Endoscopy is a potential route for infection. Because of this reason, gastroenterology associations around the world recommended the suspension of non-emergency endoscopy. The aim of our study was to investigate the characteristics of the emergency endoscopic procedures performed during the pandemic period and compare with the same period of the previous year. Material and Methods Our endoscopy unit is the only center in the city where emergency endoscopic intervention and therapeutic endoscopic procedures are performed on adult patients. Only emergency and urgent endoscopic procedures performed between March 16 and May 18, the period when the pandemic was most intense, were evaluated. The staff in the endoscopy room used full personal protective equipment all endoscopic procedures irrespective of whether or not to test for COVID-19. Results 96 upper endoscopic (56 of them GI bleeding), 26 lower endoscopic (14 of them GI bleeding, mostly malignancy) and 27 ERCP procedures were carried out. Only one patient that 62 years old male, with a negative typical symptom query, was detected PCR positive for COVID-19 on the same day after the procedure. In the same period in 2019, we had performed 98 upper and 25 lower endoscopies and 99 ERCP for emergency indications. Conclusion COVID-19 pandemic process caused extreme changes in endoscopy procedure practice and also indications. All endoscopy units should always be accoutered for the management of emergency endoscopy procedures such as gastrointestinal bleeding.

Regular endoscopic surveillance and polypectomy is effective in managing rectal adenoma progression following colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis.

Total colectomy with ileorectal anastomosis (TC-IRA) is a surgical option for patients with familial adenomatous polyposis (FAP). Regular endoscopic surveillance of the rectum is recommended to prevent rectal cancer. We aimed to document polyp progression in the rectum following TC-IRA and evaluate the role of polypectomy during surveillance. Patients with FAP who underwent TC-IRA between 1990 and 2017 were identified. Demographic, endoscopic and genetic data were retrieved. Cumulative rectal adenoma (polyp) counts were obtained, whilst accounting for any polypectomies during the study period. The rate of polyp progression and factors influencing secondary proctectomy were evaluated. One hundred and ninety-nine patients fulfilled our inclusion criteria, of which 44% were male. The median age at colectomy was 19 (range 11-70) years and median preoperative rectal polyp count was 7 (range 0-50). All patients had an APC pathogenic variant, of which 151 (79%) were 5' of the mutation cluster region (MCR), 19 (10%) in the MCR, six (3%) were 3' of the MCR and 15 (8%) had a gross deletion. After a median follow-up of 8.6 (range1-27) years and a median of 11 (range 2-37) flexible sigmoidoscopies per patient, the median rate of polyp progression was 5.5 polyps/year (range 0-70.2). There was no evidence of polyp regression. Eight (4%) patients underwent secondary proctectomy for neoplasia, of which one (0.5%) had rectal adenocarcinoma. A total of 13,527 polyps were removed, a median of 35 polyps/patient (range 0-829). The rate of polyp progression was not significantly associated with genotypic or phenotypic factors. Progression of rectal adenoma burden following TC-IRA appears to be slow and dependent on the length of follow-up. In the modern era of stringent endoscopic surveillance and therapeutic procedures such as cold snare polypectomy, the rate of secondary proctectomy and the risk of rectal cancer after TC-IRA are very low. These findings are important when counselling patients with regard to the choice of surgery for FAP and implementing endoscopic surveillance.

Early versus delayed feeding after therapeutic endoscopic procedures: Meta-analysis of randomized controlled trials.

Early feeding was previously considered to increase the risk of postprocedural bleeding. However, many trials have demonstrated the benefits of early feeding after therapeutic endoscopic procedures. We conducted a meta-analysis of randomized controlled trials to evaluate the safety and outcomes between early feeding and delayed feeding after therapeutic endoscopic procedures. Medline (PubMed), Embase, Google Scholar, the Cochrane Library, and clinicaltrials.gov were searched to identify randomized controlled trials that met our inclusion criteria. The pooled data for the mortality rate, postprocedural bleeding rate, and length of hospital stay were analyzed. A total of seven trials consisting of 717 patients were reviewed. These seven trials examined various therapeutic endoscopic procedures. Three trials included patients undergoing endoscopic hemostasis for upper gastrointestinal bleeding, two included patients undergoing esophageal variceal ligation, and two included patients with gastric neoplasm treated with endoscopic submucosal dissection. Although no significant differences were observed in the postprocedural bleeding rate or the mortality rate between patients who received early feeding and those who received delayed feeding, early feeding resulted in shorter hospital stays (weighted mean difference -1.04, 95% confidence interval -1.45 to 0.63). Early feeding appears to be a safe management method for patients undergoing therapeutic endoscopic procedures. Therefore, we recommend early feeding for these patients.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in the very elderly by using a combination of intravenous midazolam, ketamine and pethidine.

The number of therapeutic endoscopic procedures in elderly individuals keeps increasing and this population has a high risk of adverse events related to sedation and general anesthesia. However, there is a paucity on data about the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in this population. In total, 417 consecutive ERCP procedures were performed in 362 patients between September 2018 and January 2020. Of these, 59 patients (74 sessions) were aged ≥80 years (Group A) and 173 patients (193 procedures) were aged ≤65 years (Group B). We analyzed the prospectively collected data of patient- and procedure-related variables. The procedure time was significantly longer in Group A (P < 0.05). The prevalence of comorbidities, use of anticoagulants and American Society of Anesthesiologists (ASA) physical status classification levels were significantly higher in Group A (P < 0.05). The incidence of periampullary diverticula, malignancy, rate of difficult cannulation, mean number of stones, use of biliary stents and stent dysfunction was also significantly higher in Group A (P < 0.05). The medication doses used were significantly higher and emergence symptoms were significantly more frequent in Group B (P < 0.05). The rates of bleeding, pancreatitis, perforation, cholangitis, hypoxia, hypotension and the length of hospital stay did not significantly differ between the two groups. The overall success rate of the procedure was comparable in the two groups (P=0.874). ERCP can be safely performed in elderly patients using a combination of midazolam and ketamine without propofol. The incidence of complications is comparable with that observed in younger patients. Geriatr Gerontol Int 2021; 21: 887-892.

Evolution in the Practice of Pediatric Endoscopy and Sedation.

The fields of pediatric gastrointestinal endoscopy and sedation are critically important to the diagnosis and treatment of gastrointestinal (GI) disease in children. Since its inception in the 1970s, pediatric endoscopy has benefitted from tremendous technological innovation related to the design of the endoscope and its associated equipment. Not only that, but expertise among pediatric gastroenterologists has moved the field forward to include a full complement of diagnostic and therapeutic endoscopic procedures in children. In this review, we discuss the remarkable history of pediatric endoscopy and highlight current limitations and future advances in the practice and technology of pediatric endoscopy and sedation.