Success of repeat ERCP by the same endoscopist.

BACKGROUND: The success rate of repeat endoscopic retrograde cholangiopancreatography (ERCP) by the same endoscopist after a failed initial attempt is unknown. It has been suggested that a repeat examination at a tertiary referral center be performed after an unsuccessful attempt. Our aim was to determine the success rate of repeat ERCP at a different endoscopic session by the same endoscopist and the outcomes among patients with a failed index procedure. METHODS: A review of 500 consecutive ERCP procedures was performed at a teaching institution. RESULTS: The overall initial success rate for cannulation of the duct of interest was 90.8% at index endoscopy. Endoscopy was repeated after 51% unsuccessful procedures, and access to the desired duct was achieved in 87.5% of repeat attempts. A needle knife was used in 21% instances, and its use facilitated cannulation of the duct of interest in 80%. No complications occurred with repeat ERCP. Of the 3 patients who underwent failed repeated ERCP, 1 was not available for the follow-up study, 1 had metastatic cancer, and the other had pancreas divisum. The outcomes among patients who did not undergo repeat ERCP included malignant disease diagnosed with other imaging techniques (35% of patients) and no further admissions or emergency room visits for suspected pancreaticobiliary symptoms (39% of patients). CONCLUSIONS: Repeat ERCP by the same endoscopist yields an 87.5% success rate. This leads to an overall success rate of 95%.

Esophageal self-expandable metallic stents--indications, practice, techniques, and complications: results of a national survey.

BACKGROUND: The gastroenterology community's experience with esophageal self-expandable metallic stents (SEMS) is unknown. METHODS: In order to assess indications, perioperative management, and self-reported complications associated with SEMS placement, a survey was mailed to ASGE members. RESULTS: Of 3414 surveys mailed, 212 (6.2%) were completed and returned. One hundred twenty-eight physicians had experience with a total of 434 SEMS. Most physicians practiced in the private sector (72%), and 75% had placed 3 or fewer SEMS. Perceived ease of placement was the most common reason for choosing a SEMS (55%). Fluoroscopic and endoscopic guidance was used by 83% of respondents, and 81% allowed liquid diet after correct position and patency had been confirmed; 56% of respondents discharged their patients within 24 hours of SEMS placement. The rates of failure for full expansion (7.1%), stent misplacement (4.8%), and failure to deploy (3%) were higher than previously reported. Acute patient complications and delayed bleeding occurred less frequently than in reported series but mortality rates were similar. CONCLUSIONS: Ease of placement is the main reason for choosing a SEMS. Differences in complication rates, compared to previous studies on SEMS, may be related to operator experience and protocol requirements. When compared to plastic stents, complications were less frequent.

A prospective evaluation of the endoscopic spectrum of overtube-related esophageal mucosal injury.

BACKGROUND: Placement of an overtube is required for endoscopic variceal ligation. The spectrum of overtube-related esophageal mucosal injury is unknown. We made a prospective comparison of two types of overtubes and a determination of the frequency, severity, and risk factors for overtube-related injury. METHODS: Two overtubes (60F, 20 cm, "new" overtube; and 60F, 25 cm, "old" overtube) were used and placed using the bougie-assisted technique. Mucosal integrity was documented before and after variceal ligation. Overtube contact time, bands number, setting (emergent versus elective), type of overtube, degree of coagulopathy, and development of symptoms after variceal ligation were recorded. RESULTS: Fifty sessions in 29 patients were analyzed; 24% of sessions were emergent. The old overtube was used in 24 sessions and the new in 26. Mucosal injury occurred in 72% of sessions. Mean overtube contact time was 11.58 +/- 0.97 minutes, the mean number of bands placed per session was 6.4 +/- 0.4, and the mean international normalized ratio was 1.47 +/- 0.06. No risk factors correlated with mucosal injury except for the old overtube, which was associated with tears (p = 0.02). CONCLUSIONS: Mucosal injury related to the overtube is frequent but clinically unimportant. Because mucosal tears occurred significantly more often with the old overtube, we suggest that its use should be avoided.

Techniques and complications of esophageal foreign body extraction in children and adults.

To assess the success rates and complications of esophageal foreign body extraction in adult and pediatric patients, the charts of 76 adults and 116 children with endoscopically or radiographically documented esophageal foreign body impaction were retrospectively reviewed. Success rates for rigid esophagoscopy (100%) and flexible endoscopy (96.2%) were not significantly different (p > 0.05). Overall, rigid esophagoscopy had a higher complication rate than flexible endoscopy (10% versus 5.1%, p > 0.05), but this trend did not reach statistical significance. The Foley catheter technique was used predominantly in children with proximally located blunt objects. Our study shows that flexible and rigid esophagoscopy are both safe and effective methods of removing esophageal foreign bodies, but rigid esophagoscopy carries a higher complication rate and therefore should be reserved for patients in whom flexible endoscopy is unsuccessful. The Foley catheter technique is suited only for proximally located blunt objects, and its routine use is not recommended.

Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy.

Esophageal variceal ligation and esophageal variceal sclerotherapy are two modes of therapy commonly used in the treatment of esophageal varices. The purpose of this study was to compare the local complications of these procedures, with special emphasis on production and healing of ulcerations. Twenty-three patients entered the study. Ten patients were randomized to esophageal variceal ligation and 13 to esophageal variceal sclerotherapy. Esophageal variceal ligation produced shallow (0.6 +/- 0.07 mm) circular ulcerations with a large surface area (85.4 +/- 20.3 mm2) that resolved in 14.4 +/- 1.4 days. Esophageal variceal sclerotherapy produced linear, deep ulcerations (1.8 +/- 0.01 mm) with a smaller surface area (13.3 +/- 2.8 mm2) and resolution in 20.9 +/- 1.3 days. These differences were statistically significant by independent t test (p < 0.0001). Esophageal variceal ligation patients required 3.6 +/- 0.4 sessions to achieve obliteration, whereas esophageal variceal sclerotherapy patients required 6.2 +/- 0.5 sessions (independent t test, p < 0.0001). No significant difference was noted between the two groups with regard to death or stricture formation.

Sigmoidoscopy training for nurses and resident physicians.

Five gastrointestinal nurses (three licensed practical nurses and two registered nurses) and five resident physicians were enrolled in a sigmoidoscopy training protocol. Patients referred for a screening sigmoidoscopy were randomized to have the procedure performed by a nurse or a resident. Objective criteria for proficiency were depth of endoscope insertion, procedure time, and identification of anatomic landmarks and pathologic lesions; subjective criteria included thoroughness and the need for assistance. Four nurses and all of the residents were deemed proficient at a mean of 20 procedures in both groups. One registered nurse did not achieve proficiency after 35 procedures; this determination was based on subjective criteria. Insertion depth and identification of normal anatomy improved with experience. Trainees missed 1.4% of pathologic lesions, and no complications were observed. Nurses can be trained to perform a screening sigmoidoscopy in a safe and effective manner, with results similar to those for doctors.

Mercury bougie dilation of benign esophageal strictures.

Dilation with mercury filled bougies is the oldest and simplest technique available for treatment of benign esophageal strictures. In the majority of patients, mercury-filled dilators are effective and quite safe. Dilation is successful in 80-90%, and the rate of complication is less then 0.2%. Maloney dilators have superseded Hurst dilators because their tapered, flexible tip allows better guidance of the dilators into the lumen of the stricture. Several cautions are in order when using Maloney dilators. Dilation of difficult strictures should be observed by fluoroscopy to prevent misdirection of the dilator and esophageal perforation. Where possible, Maloney dilators should not be used to treat narrow, elongated, or angulated strictures. Dilation need not be rushed. Treatments may be repeated over months to years, both to achieve symptomatic relief initially and to maintain that state. Finally, patients susceptible to endocarditis require antibiotic prohylaxis prior to treatment.

The effects of inhaled albuterol and oral theophylline on gastroesophageal reflux in patients with gastroesophageal reflux disease and obstructive lung disease.

Patients with gastroesophageal reflux disease may have pulmonary symptoms due to repeated aspiration of gastric contents or reflex bronchospasm during a reflux event. Oral bronchodilators are known to worsen gastroesophageal reflux and may lead to vicious cycle when gastroesophageal reflux causes bronchospasm. The effect of inhaled bronchodilators on gastroesophageal reflux is unknown. We compared the severity of gastroesophageal reflux in patients with documented gastroesophageal reflux disease and obstructive lung disease while they were taking inhaled albuterol or oral theophylline. Nine patients with gastroesophageal reflux disease had 24-hour esophageal pH studies on two separate days approximately 1 week apart. On one study day, the patients received 0.5 mg of albuterol in 2.5 mL of normal saline vias hand-held nebulizer, four times a day. On the other day, the patients received sustained-release theophylline, 200 mg twice a day, or in a dosage taken previously to achieve a serum theophylline level of 55 to 110 mumol/L. The patients had 40% reduction in the total time the pH was less than 4.0 with albuterol than with theophylline (9.7% vs 16.1%). Seven patients had less gastroesophageal reflux while taking albuterol, and two patients had essentially no change. Patients with gastroesophageal reflux disease, who require bronchodilator therapy for obstructive lung disease, have less reflux with inhaled albuterol.

Improved patient care using the A/S/G/E guidelines on quality assurance: a prospective comparative study.

The American Society for Gastrointestinal Endoscopy has promulgated guidelines on quality assurance in gastrointestinal endoscopy. Thorough documentation of endoscopy reports and a peer review process were strongly recommended. We evaluated 1408 dictated endoscopy and colonoscopy reports for deficiency in reference to the guidelines during three periods: 6 months before (group 1), 6 months after the application of the guidelines (group 2), and 5 months of intensive peer review process (group 3). Deficiency was defined as lack of documentation of at least 1 of the 10 parameters that should be included in endoscopy reports according to the guidelines. There was a significant decrease in deficiency rates in groups 2 (91.6%) and 3 (32.7%) compared with group 1 (99.8%) (p less than 0.01). Peer review and direct confrontation of the endoscopists with their deficiencies significantly reduced the use of inappropriate indication for endoscopy (1.5%/group 3 vs. 5.2%/group 1, p less than 0.01). Adherence to the A/S/G/E guidelines on quality assurance improved documentation, decreased inappropriate use of endoscopy, and may thus improve quality of care.

Gastroenterology consultations from the internal medicine physician's perspective.

OBJECTIVE: To examine the patterns of use of gastroenterology consultations by internal medicine physicians. DESIGN: A survey of licensed physicians in the three metropolitan areas in Arizona where gastroenterologists are available. The physicians were asked how likely they were to obtain gastroenterology consultations for a variety of different gastrointestinal illnesses. Comparisons between groups were done with chi-square analysis. MEASUREMENTS AND MAIN RESULTS: Forty-six percent of the physicians responded. The majority of respondents believed that esophagogastroduodenoscopy and colonoscopy should be available without gastroenterology consultation (65% and 64%, respectively). Physicians in practice more than ten years were less prone to request consultation for gastrointestinal complaints that were likely to result in endoscopic procedures, such as the diagnosis of peptic ulcer disease or inflammatory bowel disease, or guaiac-positive stool. Internal medicine residents were more likely to seek consultations for both endoscopic and cognitive gastrointestinal complaints. Internal medicine residents were far more likely to request gastroenterology consultations for most patients with upper-gastrointestinal-tract bleeding (91% vs. 60%, p less than 0.001) and lower-gastrointestinal-tract bleeding (65% vs. 22%, p less than 0.0001) than were internists practicing more than ten years. CONCLUSIONS: The majority of internal medicine physicians would like to order endoscopic procedures without gastroenterology consultations, much as they order radiography. Recently trained physicians are far more likely to request consultants for procedure-related problems.