Utilization Of Endoscopy Research Articles

Time progression from the patient’s operating room entrance to incision: factors affecting anesthetic setup and surgical preparation times

Owing to recent advances in surgical technology, substantial time is required for preparing surgical equipment before incision. The purpose of this study was to demonstrate the time progression from a patient's operating room entrance to incision and to evaluate the duration of each anesthetic procedure and surgical preparation. We marked the following seven points on the anesthetic chart: (1) entrance; (2) i.v. line placement; (3) preoxygenation; (4) intubation; (5) completion of patient positioning (Anesth-Set); (6) applying antiseptic solution; and (7) incision. Afterward, we analyzed the event time periods according to anesthetic procedure, patient position, surgical service, and surgical procedure (such as the utilization of endoscopy, navigation systems, and sentinel lymph node biopsy). On average, it took approximately 3 min to start i.v. placement, 7 min until preoxygenation, 15 min until intubation, and 30 min until Anesth-Set. Epidural, arterial, and central venous catheterization required 15, 9, and 13 min, respectively. It took 20 min from Anesth-Set to incision, on average; 22, 4, and 5 min were required to prepare the navigation system, endoscope, and sentinel lymph node biopsy, respectively. In total, it took an average of 49.8 +/- 17.1 min from entrance to incision, which was significantly longer (30.4 +/- 8.8 min) than it took in 1985-1986. The mean time taken from the patient's operating room entrance to incision is now significantly longer than before. This may be attributed, at least in part, to the preparation of equipment associated with new surgical technologies.

Response to Ramsey and Colleagues

To the Editor: In their letter (1), Drs Ramsey, Shaib, and Graham raise a number of important issues in response to our recent article on utilization of surveillance endoscopy in patients with gastric ulcers (2). As we state in our article, we agree wholeheartedly that medical care needs to be tailored to the individual patient. However, we disagree with the assertion of our colleagues that endoscopists are most likely to be appropriately tailoring their care in this case.

A Cost Analysis of the Diagnostic Workup of heartburn Symptoms in Patients with Erosive and Non-Erosive Reflux Disease

Purpose: Gastroesophageal Reflux Disease (GERD) is the most common cause of outpatient visits to gastroenterology clinics in the United States. While many studies have examined the epidemiologic differences between patients with Non-Erosive Reflux Disease (NERD) and Erosive Esophagitis (EE), very few have compared the utilization of health care resources in these two patient groups. Our goals were: 1) Compare the costs of the diagnostic workup for heartburn symptoms in patients with NERD and EE 2) Identify the key areas which account for disparities in health care costs. Methods: A chart review was performed on 122 patients who underwent upper endoscopy for heartburn symptoms at the San Diego Veterans' Affairs Hospital from 2000–2007. Patients were then divided into two categories: 1) EE based upon the presence of esophageal erosions on upper endoscopy (N = 56) 2) NERD based upon the absence of endoscopic erosions (N = 66). Using cost data, we then calculated the per patient cost of performing a diagnostic workup for heartburn symptoms in these two patient groups. Results: There were no significant differences in the age, gender, BMI or the presence of hiatal hernia in the two groups (Table 1). 54% of the NERD group had a concomitant psychiatric disorder compared with 37.5% in EE (P= 0.03). The cost of the diagnostic workup for NERD was $2793.26 per patient compared with $2091.00 per patient in the EE group (P= 0.027). While the utilization of endoscopy was similar in both groups, utilization of GI clinic visits, pH/motility testing, and diagnostic imaging was greater among patients with NERD (Fig. 1). Overall, pH/motility testing and GI clinic visits accounted for 40% and 51% respectively of the extra costs found in the NERD group.FigureTable 1: Patient Characteristics.Conclusion: Health care utilization is greater in NERD than in EE. This may be a consequence of the fact that patients with NERD have a lower response rate to PPI therapy, thus prompting more frequent clinic visits. In addition, the over-utilization of motility/pH testing and diagnostic imaging in NERD may also drive up costs. The increased rate of co-morbid psychiatric disease in NERD raises the possibility that somatization may lead to the increased use of health care resources.

Neoplastic precursor lesions of the upper gastrointestinal tract

Carcinomas of the oesophagus and stomach are major causes of morbidity and mortality in high prevalence regions, such as Eastern Asia. The incidence rate of adenocarcinoma of the gastro-oesophageal junction is also increasing in the US. Most carcinomas of the upper gastrointestinal (GI) tract develop in association with multifocal dysplasia and occur in patients with long-standing mucosal injury. Not surprisingly, increased utilization of endoscopy and mucosal biopsy in the evaluation of patients with upper GI tract symptoms has led to the frequent detection of mucosal atrophy, intestinal metaplasia and glandular dysplasia. Although appropriate classification of these lesions is straightforward in most cases, inflammation-induced epithelial changes may closely simulate, or mask, dysplasia, resulting in diagnostic confusion or precluding definitive diagnosis in some cases. Emerging evidence also suggests that specific molecular changes in non-dysplastic oesophageal and gastric mucosa herald the development of dysplasia and/or carcinoma, indicating that ancillary molecular analyses may play a role in the future management of high-risk patients. The purpose of this review is to discuss the clinical, pathological and molecular features of pre-cancerous lesions of the upper GI tract, as well as the potential pitfalls in their recognition and classification.

Outcomes of Weekend Admissions for Upper Gastrointestinal Hemorrhage: A Nationwide Analysis

Previous studies have identified a weekend effect in outcomes of patients with various medical conditions suggesting worse outcomes for weekend admissions. The aim of our study was to analyze if weekend admissions for upper gastrointestinal hemorrhage (UGIH) have higher mortality and longer hospital stay compared with those admitted on weekdays, and to examine if this effect differs by hospital teaching status. This was a cross-sectional study using the Nationwide Inpatient Sample 2004. A total of 28,820 discharges with acute variceal hemorrhage (AVH) and 391,119 discharges with acute nonvariceal UGIH (NVUGIH) were identified through appropriate International Classification of Diseases, ninth edition codes. Admissions were considered to be weekend admissions if they were admitted between midnight on Friday through midnight on Sunday. In-hospital mortality, frequency, and timing of endoscopy were measured. On multivariate analysis, NVUGIH patients admitted on weekends had higher adjusted in-hospital mortality (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09-1.35) and were less likely to undergo early endoscopy within 1 day of hospitalization (OR, 0.64; 95% CI, 0.61-0.68). Weekend admission was not predictive of in-hospital mortality in patients with AVH (OR, 0.94; 95% CI, 0.75-1.18), but was associated with lower likelihood of early endoscopy in nonteaching hospitals (OR, 0.65; 95% CI, 0.51-0.82). Early endoscopy was associated with significantly shorter hospital stays (NVUGIH, -1.08 days; AVH, -2.35 days) and lower hospitalization charges (NVUGIH, -$1958; AVH, -$8870). Patients with NVUGIH admitted on the weekend had higher mortality and lower rates of early endoscopy. Patient with AVH admitted to nonteaching hospitals also had lower utilization of early endoscopy, but no difference in survival. There is a need for research into identifying the reasons for the weekend effect.

Utilization of Upper Endoscopy for Surveillance of Gastric Ulcers in the United States

Current guidelines recommend that all gastric ulcers (GUs) be biopsied extensively to exclude underlying malignancy. However, many gastroenterologists opt to also perform surveillance endoscopy (EGD) to document ulcer healing. The purpose of this study was to examine frequency of utilization of surveillance EGD in patients found to have GUs using a national endoscopic database. The Clinical Outcomes Research Initiative (CORI) database was used to identify ambulatory patients diagnosed with a GU between 2001 and 2005. A surveillance EGD was defined as any EGD performed < or =3 months after index EGD. Results were stratified by patient demographic factors, index ulcer size and location, practice setting, and geographic region. Multivariate logistic regression was performed to identify independent predictors of surveillance EGD utilization. In the database, 6,113 patients met our inclusion/exclusion criteria, of which 1,510 (24.7%) underwent surveillance EGD. Older patients were more likely to undergo surveillance than younger patients (P < 0.0001), though a substantial minority (15.2%) of patients <40 years of age underwent a surveillance examination. Index ulcer size > or =1 cm and care in a Veterans Affairs (VA) setting were also independent predictors of surveillance EGD utilization. Significant geographic variation was noted, with surveillance rates varying from 16.0% to 35.9% across the United States (P < 0.0001). In contrast to guideline recommendations, approximately 25% of ambulatory patients diagnosed with GUs underwent surveillance EGD within 3 months. Notably, patients at low-risk for gastric cancer, including young patients, those with small index ulcers, and those with antral ulcers, underwent surveillance at higher than expected rates, which suggests overuse of surveillance EGD.

Utilization of Upper Endoscopy for Surveillance of Gastric Ulcers: Results from the National Endoscopic Database

Background: Despite guideline recommendations, data suggest that endoscopists frequently perform endoscopic surveillance (EGD) of gastric ulcers (GUs) to document healing, a practice that is meant to exclude underlying malignancy. The low prevalence of gastric cancer and the high diagnostic sensitivity of multiple ulcer biopsies at initial EGD make this approach unlikely to be beneficial. Despite concerns of overuse, however, no study has examined how endoscopists in the United States manage GUs. In addition, no study has looked at utilization data rather than self-reported practice patterns. Methods: The National Endoscopic Database (CORI database) was used to identify ambulatory patients diagnosed with a GU between 2001 and 2005. A surveillance EGD was defined as any EGD performed ≤3 months after this index EGD. Exclusion criteria were: (1) past history of gastric surgery; (2) past history of gastric cancer; and, (3) EGD performed within the previous 12 months. Results were stratified by: (1) patient age, ethnicity, and gender; (2) ulcer size; (3) practice setting; and, (4) geographic region. Multivariate logistic regression was performed to identify independent predictors of surveillance EGD. Results: 6113 patients with GUs meeting the aforementioned inclusion and exclusion criteria were identified in the database. Of these, 25% (n = 1510) underwent surveillance EGD. Older patients were more likely to undergo surveillance than younger patients (p < 0.0001), though a substantial minority (15%) of patients <40 years underwent a surveillance exam. Patients with ulcers ≥1 cm in size were also more likely to undergo surveillance (33% vs 22%, p < 0.0001). VA patients were significantly more likely to undergo surveillance exams than non-VA patients (37% vs 23%, p < 0.0001). Geographic variation was also noted, with surveillance rates varying from 16% to 36% across the United States (p < 0.0001). All of these factors were independently predictive of surveillance EGD in multivariate logistic regression analysis. Surveillance rates did not appear to differ substantially on the basis of gender and ethnicity. Conclusions: In contrast to guideline recommendations, >25% of ambulatory patients diagnosed with GUs undergo surveillance EGD within 3 months. This rate varies significantly by patient age, ulcer size, practice setting, and geographic location. However, young patients, those with small ulcers, and those within the VA system continue to undergo surveillance at higher than expected rates, suggesting continued overuse. Future research should study the impact of interventions designed to decrease the overuse of EGD for GU surveillance.

The GIST of a stromal tumor

The GIST of a stromal tumor

ASGE Guideline: guidelines for endoscopy in pregnant and lactating women

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear Clinical consideration may justify a course of action at variance to these recommendations.

ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

ASGE guideline: complications of EUS

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

The role of EUS for evaluation of mediastinal adenopathy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

The role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Obscure gastrointestinal bleeding

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Guidelines for Antibiotic Prophylaxis for GI Endoscopy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Guidelines for Conscious Sedation and Monitoring During Gastrointestinal Endoscopy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Tissue sampling and analysis

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts.

The role of endoscopic therapy in the management of variceal hemorrhage

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. A previous guideline related to this topic (ASGE Publication No. 1019, Gastrointest Endosc 1989;6:600-1) was published in 1989. Since that time, new information has become available, which requires an update of this statement and its recommendations. In preparing this update, a Medline literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from the recommendations of expert consultants.

Role of endoscopy in enteral feeding

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. A previous guideline related to this topic (ASGE Publication No. 1017, Gastrointest Endosc 1998;48:699-701). Since that time, new information has become available that requires an update of this statement and its recommendations. In preparing this update, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. When inadequate data existed from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts.Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance from these recommendations.