Lukejohn W. Day

Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis

BACKGROUND Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes. OBJECTIVE To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups. SETTING AND PATIENTS Elderly patients undergoing colonoscopy. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASUREMENTS Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality. RESULTS Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0-27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9-1.5) for perforation, 6.3 (95% CI, 5.7-7.0) for GI bleeding, 19.1 (95% CI, 18.0-20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7-2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9-38.0), perforation rate of 1.5 (95% CI, 1.1-1.9), GI bleeding rate of 2.4 (95% CI, 1.1-4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2-31.8), and mortality rate of 0.5 (95% CI, 0.06-1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5-1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2-2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant. LIMITATIONS Heterogeneity of studies included and not all complications related to colonoscopy were captured. CONCLUSIONS Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.

Idiopathic AIDS Enteropathy and Treatment of Gastrointestinal Opportunistic Pathogens

Diarrhea in patients with acquired immune deficiency syndrome (AIDS) has proven to be both a diagnostic and treatment challenge since the discovery of the human immunodeficiency virus (HIV) virus more than 30 years ago. Among the main etiologies of diarrhea in this group of patients are infectious agents that span the array of viruses, bacteria, protozoa, parasites, and fungal organisms. In many instances, highly active antiretroviral therapy remains the cornerstone of therapy for both AIDS and AIDS-related diarrhea, but other targeted therapies have been developed as new pathogens are identified; however, some infections remain treatment challenges. Once identifiable infections as well as other causes of diarrhea are investigated and excluded, a unique entity known as AIDS enteropathy can be diagnosed. Known as an idiopathic, pathogen-negative diarrhea, this disease has been investigated extensively. Atypical viral pathogens, including HIV itself, as well as inflammatory and immunologic responses are potential leading causes of it. Although AIDS enteropathy can pose a diagnostic challenge so too does the treatment of it. Highly active antiretroviral therapy, nutritional supplementation, electrolyte replacements, targeted therapy for infection if indicated, and medications for symptom control all are key elements in the treatment regimen. Importantly, a multidisciplinary approach among the gastroenterologist, infectious disease physician, HIV specialists, oncology, and surgery is necessary for many patients.

Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth

Small intestinal bacterial overgrowth (SIBO) is an under‐recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear.

Colorectal Cancer Screening and Surveillance in the Elderly Patient

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Older age is associated with a rise in colorectal cancer and adenomas, necessitating the need for CRC screening in older patients. However, decisions about CRC screening and surveillance in older adults are often difficult and challenging. The decision requires an individualized assessment that incorporates factors unique to performing colonoscopy in older adults in order to weigh the risks and benefits for each patient according to their overall health and preferences. This review addresses the factors unique to colorectal cancer and performing colonoscopy in older adults that are relevant in weighing the risks and benefits of screening and surveillance in this population.

Guidelines for Safety in the Gastrointestinal Endoscopy Unit

In 2009, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage eliminated the distinction between a sterile operating room and a non-sterile procedure room. Hence, GI endoscopy units are now held to the same standards as sterile operating rooms by CMS1 without evidence demonstrating that safety or clinical outcomes in endoscopy are thereby improved. Although the ASGE has previously published guidelines on staffing, sedation, infection control, and endoscope reprocessing for endoscopic procedures (Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011; Infection control during GI endoscopy; Minimum staffing requirements for the performance of GI endoscopy; Multisociety sedation curriculum for gastrointestinal endoscopy)2, 3, 4, 5 the purpose of this document is to present recommendations for endoscopy units in implementing and prioritizing safety efforts and to provide an endoscopy-specific guideline by which to evaluate endoscopy units. As a general principle, requirements for safety ought to be rooted in evidence that demonstrates a benefit in outcomes. Where data is absent, these requirements may be derived from experts with experience in the safe delivery of care in the GI endoscopy setting. Additionally, consideration should be given to the promotion of efficient care and cost containment with avoidance of requirements unsupported by evidence that then contribute to rising healthcare costs. Over the past 2 years, surveyors have called into question accepted practices at many accredited endoscopy units seeking re-accreditation. Many of these issues relate to the Ambulatory Surgical Center (ASC) Conditions for Coverage set forth by CMS and the lack of distinction between the sterile operating room and the endoscopy setting. The following is a summary of issues that have been faced by endoscopy units throughout the country along with ASGE’s position and accompanying rationale. Issue: Structural requirements for 40-inch doors and room sizes >400 square feet required of sterile operating rooms. Position: Standard 36-inch doors, if they accommodate patient transport mechanisms, and room sizes 180 square feet are adequate and safe for endoscopy units because they do not use the same large equipment or number of staff as in the operating room.6 Issue: Requirement for a written policy on traffic patterns in the endoscopy unit. Position: The unit should define low-risk exposure and high-risk exposure areas and activities within the endoscopy unit, and describe the attire and personal protective equipment that should be worn in each area. Endoscopy staff can move freely throughout the unit provided that there is appropriate use and changing of personal protective equipment. Issue: Requirement for endoscopy personnel to don full sterile operating room personal protective equipment including new scrubs, hair covers and booties. Position: It is recommended that staff directly engaged in GI endoscopy or in processes where splash or contamination could occur should wear gloves, face/eye shields, and an impervious gown. Units should develop policies that are consistent with OSHA and state-mandated recommendations for wearing face/eye shields or masks.7 Scrubs or other attire may be worn from home because endoscopy is not a sterile procedure. Likewise, there is no need for hair covers or booties. Staff must remove and appropriately discard used PPE before leaving the procedure area. Issue: Supervision of moderate sedation. Position: Moderate sedation may be administered safely under the supervision of a non-anesthesia physician who is credentialed and privileged to do so. Issue: Role of capnography. Position: There is inadequate data to support the routine use of capnography where moderate sedation is the target. Issue: Requirement that 2 nurses (one monitoring, one circulating) are present when moderate sedation is performed. Position: When moderate sedation is the target, a nurse should monitor the patient and can perform interruptible tasks. If more technical assistance is required, a second assistant (nurse, licensed practical nurse, or unlicensed assistive personnel) should be available to join the care team. Issues: Staffing requirements when sedation and monitoring is provided by anesthesia personnel. Position: When sedation and monitoring is provided by anesthesia personnel, a single additional staff person (nurse, licensed practical nurse, or unlicensed assistive personnel) is sufficient to assist with technical aspects of the procedure. Issue: Technical capabilities of technicians. Position: Unlicensed technicians, who have received initial orientation and ongoing training, and are deemed competent by their unit, can assist with and participate in tissue acquisition during the endoscopic procedure, including but not limited to the opening and closing of forceps, snares, and other accessories.

Non-physician performance of lower and upper endoscopy: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS Demand for endoscopic procedures worldwide has increased while the number of physicians trained to perform endoscopy has remained relatively constant. The objective of this study was to characterize non-physician performance of lower and upper endoscopic procedures. PATIENTS AND METHODS Bibliographical searches were conducted in Medline, EMBASE, and Cochrane Library databases. Studies were included where patients underwent flexible sigmoidoscopy, colonoscopy, or upper endoscopy done by a non-physician (nurse, nurse practitioner, physician assistant) and outcome measures were reported (detection of polyps, adenomas, cancer, and/or adverse events). Pooled rates were calculated for specific outcomes and rate ratios were determined for selected comparison groups. RESULTS Most studies involved nurses performing flexible sigmoidoscopies for colorectal cancer screening. Nurses and nurse-practitioners/physician assistants performing flexible sigmoidoscopies showed pooled polyp detection rates of 9.9 % and 23.7 %, adenoma detection rates of 2.9 % and 7.2 %, colorectal cancer detection rates of 1.3 % and 1.2 %, and adverse event rates of 0.3 and 0 per 1000 sigmoidoscopies, respectively. There was no significant difference between polyp and adenoma detection rates in sigmoidoscopy performance studies comparing nurses or nurse-practitioners/physician assistants with physicians. For the 3 studies of non-physician performance of colonoscopy, pooled adenoma detection rate was 26.4 %, cecal intubation rate was 93.5 %, and adverse event rate was 2.2 /1000 colonoscopies. In the few studies examining upper endoscopies, 99.4 % of upper endoscopy procedures performed by nurses were successful with no reported adverse events. CONCLUSION Available studies suggest that when non-physicians perform endoscopic procedures, especially lower endoscopies, outcomes and adverse events are in line with those of physicians.

Colorectal Cancer Screening and Surveillance in the Elderly: Updates and Controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

Background and study aims: Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. Patients and methods: Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. Results: Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 – 7.0), pancreatitis 13.1 (95 %CI 11.0 – 15.5), bleeding 7.7 (95 %CI 5.7 – 10.1), cholangitis 16.1 (95 %CI 11.7 – 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 – 7.6), and death 7.1 (95 %CI 5.2 – 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 – 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 – 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 – 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 – 13.9), and death (IRR 3.8, 95 %CI 1.0 – 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.

Optimizing efficiency and operations at a California safety-net endoscopy center: a modeling and simulation approach

BACKGROUND Improvements in endoscopy center efficiency are needed, but scant data are available. OBJECTIVE To identify opportunities to improve patient throughput while balancing resource use and patient wait times in a safety-net endoscopy center. SETTING Safety-net endoscopy center. PATIENTS Outpatients undergoing endoscopy. INTERVENTION A time and motion study was performed and a discrete event simulation model constructed to evaluate multiple scenarios aimed at improving endoscopy center efficiency. MAIN OUTCOME MEASUREMENTS Procedure volume and patient wait time. RESULTS Data were collected on 278 patients. Time and motion study revealed that 53.8 procedures were performed per week, with patients spending 2.3 hours at the endoscopy center. By using discrete event simulation modeling, a number of proposed changes to the endoscopy center were assessed. Decreasing scheduled endoscopy appointment times from 60 to 45 minutes led to a 26.4% increase in the number of procedures performed per week, but also increased patient wait time. Increasing the number of endoscopists by 1 each half day resulted in increased procedure volume, but there was a concomitant increase in patient wait time and nurse utilization exceeding capacity. By combining several proposed scenarios together in the simulation model, the greatest improvement in performance metrics was created by moving patient endoscopy appointments from the afternoon to the morning. In this simulation at 45- and 40-minute appointment times, procedure volume increased by 30.5% and 52.0% and patient time spent in the endoscopy center decreased by 17.4% and 13.0%, respectively. The predictions of the simulation model were found to be accurate when compared with actual changes implemented in the endoscopy center. LIMITATIONS Findings may not be generalizable to non-safety-net endoscopy centers. CONCLUSIONS The combination of minor, cost-effective changes such as reducing appointment times, minimizing and standardizing recovery time, and making small increases in preprocedure ancillary staff maximized endoscopy center efficiency across a number of performance metrics.

FIT Testing: An Overview

Colorectal cancer (CRC) is a common, but preventable, disease and is the second most common cause of cancer-related deaths in the U.S. CRC screening has proven effective at reducing both the incidence and mortality of this disease, using any of a number of screening tests available. The test options range from the least invasive and least expensive to more invasive and costly options. Fecal occult blood testing is the oldest, least expensive, and least invasive of these options and has evolved from the poorly sensitive standard guaiac test to the newer and diagnostically superior fecal immunochemical test (FIT) for hemoglobin. This article explores the evolutionary history of fecal occult blood testing, examines test performance characteristics among different FOBTs, and evaluates the role of the FIT in programmatic CRC screening.