J. Patrick Waring

Guideline for the management of ingested foreign bodies.

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. 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.

Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures

This is one of a series of statements discussing the practice of gastrointestinal endoscopy in common clinical situations. It is intended to aid endoscopists in determining the appropriate use of endoscopic procedures in conjunction with anticoagulation and/or antiplatelet therapy. Guidelines for the appropriate practice of endoscopy are based on critical review of the available data and expert consensus. Controlled clinical studies would be beneficial to clarify some aspects of this statement and revision might be necessary as new data appear. Clinical consideration may justify a course of action at variance from these specific 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.

Dysphagia after laparoscopic antireflux surgery. The impact of operative technique.

BACKGROUND Concerns about laparoscopic antireflux surgery include the frequent appearance of troublesome postoperative dysphagia. This study reviews the frequency of early (less than 6 weeks) and persistent (greater than 6 weeks) solid food dysphagia in patients undergoing Toupet, Rosetti-Nissen, or Nissen fundoplications. METHODS One hundred eighty-four consecutive patients with normal esophageal peristalsis undergoing laparoscopic antireflux surgery were prospectively studied. Before operation, all patients had endoscopy, 24-hour pH study, and an esophageal motility study. The choice of operation was dependent on anatomy and surgeon preference. Before discharge, all patients were given instructions on a soft diet. Postoperative symptoms were scored by the patients as absent, mild, moderate, or severe 4 weeks and 12 weeks after operation. The option of esophageal dilation was offered to patients with moderate to severe persistent solid food dysphagia. RESULTS New onset moderate to severe dysphagia to solid foods was present in 30 (54%), 8 (17%), and 13 (16%) patients undergoing Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively, in the first month after operation (p < 0.001). Moderate to severe dysphagia persisted at 3 months in six (11%), one (2%), and two (2%) patients undergoing laparoscopic Rosetti-Hell, Nissen, and Toupet fundoplications, respectively (p < 0.05). Esophageal dilatation was performed in five (4%), zero, and one (1%) patients undergoing laparoscopic Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively (p < 0.05). There was no additional morbidity related to division of short gastric vessels in patients undergoing Nissen fundoplication. CONCLUSIONS Laparoscopic Rosetti-Nissen fundoplication is associated with a higher rate of early and persistent postoperative dysphagia than either laparoscopic Nissen fundoplication or Toupet fundoplication. Consideration of complete fundus mobilization should be a part of all laparoscopic antireflux procedures.

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.

Complications of upper GI endoscopy

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. 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.

Diagnostic inconsistencies in Barrett's esophagus

Abstract Background/Aims: Few studies have compared the precision of various diagnostic tests used to determine the presence of Barretts esophagus. The aim of this study was to compare the results of histological, endoscopic, and manometric tests for patients with Barretts esophagus in two closely spaced examinations. Methods: In a Veterans Administration Cooperative Study, 192 patients with complicated gastroesophageal reflux disease had esophageal manometry and endoscopy performed at baseline and after 6 weeks. At each examination, the endoscopist localized the most proximal level of Barretts epithelium and the lower esophageal sphincter and obtained esophageal biopsy specimens. Results: One hundred sixteen patients met the criteria for Barretts esophagus on at least one of the two endoscopic examinations. Among patients with specialized columnar epithelium, 20% had specialized columnar epithelium found on only one of the two examinations. Although the mean lower esophageal sphincter level did not change, approximately 10% of patients had a change ≥4 cm on endoscopy and manometry between examinations. This led to an apparent change in the diagnosis in 18% of patients with Barretts esophagus. Conclusions: From one endoscopic examination to another, inconsistencies in the ability to detect specialized columnar epithelium are common. This may lead to substantial problems in establishing an accurate diagnosis of Barretts esophagus.

Methods of granting hospital privileges to perform gastrointestinal endoscopy

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. 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.

Significance of Intestinal Metaplasia in Different Areas of Esophagus Including Esophagogastric Junction

Over the past two decades, the incidence ofadenocarcinoma of the esophagus and gastric cardia hasincreased at a rate exceeding that of any other cancer.Barretts esophagus is the only known risk factor for these malignancies. Recently, emphasis hasbeen placed on the significance of specializedintestinal metaplasia (SIM) on esophageal biopsies. Ouraim was to compare the prevalence of SIM at different esophageal locations in patients who are athigher risk of developing esophageal adenocarcinoma(Caucasians) and patients with lower risk of developingesophageal adenocarcinoma (African-Americans).Eighty-seven unselected patients (42 Caucasians and 45African-Americans) underwent routine upper endoscopywith biopsies from the proximal margin of columnarmucosa. We classified patients into those with acolumnar-lined esophagus with SIM (CLE with SIM); CLE withoutSIM; or SIM with a normal-appearing gastroesophagealjunction (SIM-GEJ). The prevalence of CLE with SIM, CLEwithout SIM, and SIM-GEJ was 28%, 10%, and 10% in Caucasians compared to 0%, 18% and 11% inAfrican-Americans (P = 0.0001, 0.26, and 0.81,respectively). We found CLE with SIM only in patientswith reflux symptoms at least twice a week. It isconcluded that CLE with SIM is seen most commonly inpatients thought to be at risk for esophagealadenocarcinoma (Caucasians with reflux symptoms). It israrely seen in other groups with lower risk for thismalignancy (African-Americans, nonrefluxers). Conversely,SIM-GEJ and CLE without SIM are common in all groups andare of questionable significance.