John T. Maple

Management of antithrombotic agents for endoscopic procedures

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. This guideline combines and updates 2 previously issued guidelines, ‘‘Guideline on the management of antithrombotic and antiplatelet therapy for endoscopic procedures’’ and ‘‘ASGE guideline: the management of lowmolecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures.’’ To prepare this guideline, a search of the medical literature was performed using PubMed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as ‘‘we suggest,’’ whereas stronger recommendations are typically stated as ‘‘we recommend.’’ This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this guideline.

Complications of ERCP

d ( t s f t c s n d i a s a This is one of a series of position statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. This document is an update of a previous ASGE publication.1 In preparing this document, a search of the medical iterature was performed using PubMed. Additional refernces were obtained from the bibliographies of the identied articles and from recommendations of expert consulants. When limited or no data exist from well-designed rospective trials, emphasis is given to results from large eries and reports from recognized experts. Position stateents are based on a critical review of the available data nd expert consensus at the time that the document was rafted. Further controlled clinical studies may be needed o clarify aspects of this document, which may be revised s necessary to account for changes in technology, new ata, or other aspects of clinical practice. This document is intended to be an educational device o provide information that may assist endoscopists in roviding care to patients. This position statement is not a ule and should not be construed as establishing a legal tandard of care or as encouraging, advocating, requirng, or discouraging any particular treatment. Clinical ecisions in any particular case involve a complex analsis of the patient’s condition and available courses of ction. Therefore, clinical considerations may lead an ndoscopist to take a course of action that varies from this osition statement. Since its introduction in 1968, ERCP has become a comonly performed endoscopic procedure.2 The diagnostic nd therapeutic utility of ERCP has been well demonstrated or a variety of disorders, including the management of choedocholithiasis, the diagnosis and management of biliary nd pancreatic neoplasms, and the postoperative manageent of biliary perioperative complications.3-5 The evolution of the role of ERCP has occurred simultaneously with that of other diagnostic and therapeutic modalities, most notably magnetic resonance imaging/MRCP, laparoscopic cholecystectomy (with or without intraoperative cholangiography), and EUS. For endoscopists to accurately assess the clinical appropriateness of ERCP, it is important to have a thorough

Complications of colonoscopy

Summary Endoscopic complications are rare but inevitable, occurring in fewer than 0.35% of procedures [B]. Knowledge of potential complications and their expected frequency can lead to an improved informed consent process [C]. Complications from the procedure include perforation, hemorrhage, postpolypectomy coagulation syndrome, infection, preparation-associated complications, and death, and are more likely to occur with therapeutic procedures rather than diagnostic procedures [B]. Risk factors for poylpectomy-associated complications include the location and size of the polyp, experience of the operator, polypectomy technique and possibly the type of electrocoagulation current used [B]. Use of saline solution injection under large sessile polyps decreases depth of thermal injury [A] and may decrease complications [B]. Early recognition of complications and prompt intervention may decrease patient morbidity [C]. Treatment of complications range from supportive for postpolypectomy coagulation syndrome, to repeat colonoscopy with injection or electrocoagulation for bleeding, to surgical repair for free perforation [B]. Consideration of the risks and benefits may improve clinical outcome by identifying potential complications and taking appropriate steps to minimize the risks [C].

The role of endoscopy in the evaluation of suspected choledocholithiasis

This is one of a series of statements discussing the use 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 search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of 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 at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. Gallstone disease affects more than 20 million American adults at an annual cost of

Management of ingested foreign bodies and food impactions

6.2 billion. A subset of these patients will also have choledocholithiasis, including 5% to 10% of those undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and 18% to 33% of patients with acute biliary pancreatitis. The approach to patients with suspected choledocholithiasis requires careful consideration because missed common bile duct (CBD) stones pose a risk of recurrent symptoms, pancreatitis, and cholangitis. However, the morbidity and cost

The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus

i d t i i t i t f o This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The original guideline was published in 1995 and last updated in 2002. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).1 The strength of individual recommendations is based both on the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series

i ( n d m e This is one of a series of statements discussing the use 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 search of the medical literature was performed using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results of 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 at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).1 The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

The role of endoscopy in the management of acute non-variceal upper GI bleeding

BACKGROUND Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. OBJECTIVE To report the largest combined experience of DEN performed for WOPN. DESIGN Retrospective chart review. SETTING Six U.S. tertiary medical centers. PATIENTS A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003. INTERVENTIONS DEN for WOPN. MAIN OUTCOME MEASUREMENTS Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications. RESULTS Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN. LIMITATIONS Retrospective, highly specialized centers. CONCLUSIONS This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.

Direct Percutaneous Endoscopic Jejunostomy: Outcomes in 307 Consecutive Attempts

d c p B s i R This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few 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 at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence1 (Table 1). he strength of individual recommendations is based on oth the aggregate evidence quality and an assessment of the nticipated benefits and harms. Weaker recommendations re indicated by phrases such as “We suggest . . . ,” whereas tronger recommendations are typically stated as “We recmmend . . . .” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Wireless capsule endoscopy

BACKGROUND:Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ.OBJECTIVE:To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution.METHODS:Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed.RESULTS:Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14).CONCLUSIONS:DPEJ was associated with a moderate or severe complication in ∼10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.