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Abbreviations: CHF, congestive heart failure; EGD, esophagogastroduodenoscopy; IV, intravenous; TIA/CVA, transient ischemic attack/cerebrovascular accident.
Source publication
Data on complications of gastrointestinal endoscopic procedures are limited. We evaluated prospectively the incidence and cost of hospital visits resulting from outpatient endoscopy.
We developed an electronic medical record-based system to record automatically admissions to the emergency department (ED) within 14 days after endoscopy. Physicians e...
Citations
... Oesophagogastroduodenoscopy (OGD) is accepted as the gold standard but is expensive, time consuming and an invasive method to detect oesophageal varices [3,8]. Due to the significant mortality associated with variceal bleeding, consensus guidelines recommend endoscopic screening for oesophageal varices in patients with a new diagnosis of cirrhosis [3,9]. ...
(Non-invasive tests (NITs) are a potential alternative to screening oesophagogastroduodenoscopy OGD) for ruling out high-risk varices (HRVs) in patients with compensated advanced chronic liver disease (cACLD). This retrospective study aimed to externally validate and compare various NITs in a multi-centre Australian cohort. Patients with cACLD were enrolled between January 2013 and December 2022. Liver stiffness measurements (LSMs), clinicopathological data, and OGD results were collected. A total of 210 patients were included. The median age was 57 years and 65.7% were male. The main aetiology of cACLD was hepatitis C (41.9%), and 91.9% of patients were Child–Pugh A. HRV prevalence was 12.4%. The Baveno VI criteria (B6C) was the only NIT that could safely reduce the need for OGDs across all aetiologies of cACLD, with a negative predictive value of 98.6 and spared OGD in 33.8%. The FIB-4 would have avoided the most OGDs (71%); however, the HRV miss rate was 6%. The results suggest that the B6C is the best performing NIT in our cohort and reliably excludes HRVs in cACLD patients, regardless of aetiology. This study confirms that the Baveno VI criteria can be applied in an Australian, mixed aetiology cohort to avoid unnecessary screening OGD.
... A substantial proportion of adverse events occurred days or even weeks after the procedures (Table 2), highlighting the poor awareness and underreporting of late complications of endoscopic procedures. Studies have demonstrated that physicians performing colonoscopies are unaware of nearly 75% of the hospital admissions for adverse events after the procedure [33]. Poor awareness leads to underreporting, as A substantial proportion of adverse events occurred days or even weeks after the procedures (Table 2), highlighting the poor awareness and underreporting of late complications of endoscopic procedures. ...
... Poor awareness leads to underreporting, as A substantial proportion of adverse events occurred days or even weeks after the procedures (Table 2), highlighting the poor awareness and underreporting of late complications of endoscopic procedures. Studies have demonstrated that physicians performing colonoscopies are unaware of nearly 75% of the hospital admissions for adverse events after the procedure [33]. Poor awareness leads to underreporting, as evidenced in patients receiving invasive testing in the context of lung cancer screening programs [12][13][14]34]. ...
Background and objective:
Limited data exist regarding the adverse events of advanced diagnostic bronchoscopy, with most of the available information derived from retrospective datasets that primarily focus on early complications.
Methods:
We conducted a 15-month prospective cohort study among consecutive patients undergoing endosonography and/or guided bronchoscopy under general anesthesia. We evaluated the 30-day incidence of severe complications, any complication, unplanned hospital encounters, and deaths. Additionally, we analyzed the time of onset (immediate, within 1 h of the procedure; early, 1 h-24 h; late, 24 h-30 days) and identified risk factors associated with these events.
Results:
Thirty-day data were available for 697 out of 701 (99.4%) enrolled patients, with 85.6% having suspected malignancy and multiple comorbidities (median Charlson Comorbidity Index (IQR): 4 (2-5)). Severe complications occurred in only 17 (2.4%) patients, but among them, 10 (58.8%) had unplanned hospital encounters and 2 (11.7%) died within 30 days. A significant proportion of procedure-related severe complications (8/17, 47.1%); unplanned hospital encounters (8/11, 72.7%); and the two deaths occurred days or weeks after the procedure. Low-dose attenuation in the biopsy site on computed tomography was independently associated with any complication (OR: 1.87; 95% CI 1.13-3.09); unplanned hospital encounters (OR: 2.17; 95% CI 1.10-4.30); and mortality (OR: 4.19; 95% CI 1.74-10.11).
Conclusions:
Severe complications arising from endosonography and guided bronchoscopy, although uncommon, have significant clinical consequences. A substantial proportion of adverse events occur days after the procedure, potentially going unnoticed and exerting a negative clinical impact if a proactive surveillance program is not implemented.
... 11 Several studies have reported CCV adverse events following diagnostic EGD in the average-risk population. 8,9,12,13 However, data on CCV adverse events following surveillance EGD in patients with GC have not been reported. Therefore, we aimed to investigate the incidence of CCV adverse events, including cardiac and cerebral adverse events, arterial thromboembolism (ATE), and pulmonary embolism (PE), after surveillance EGD with or without sedation in patients with GC. ...
Background/aims:
The impact of sedation on cardio-cerebrovascular (CCV) adverse events after esophagogastroduodenoscopy (EGD) in patients with gastric cancer (GC) is unclear. We investigated the incidence rate and impact of sedation on CCV adverse events after surveillance EGD in patients with GC.
Methods:
We performed a nationwide population-based cohort study using the Health Insurance Review and Assessment Service databases from January 1, 2018, to December 31, 2020. Using a propensity score-matched analysis, patients with GC were divided into two groups: sedative agent users and nonusers for surveillance EGD. We compared the occurrence of CCV adverse events within 14 days between the two groups.
Results:
Of the 103,463 patients with GC, newly diagnosed CCV adverse events occurred in 2.57% of patients within 14 days after surveillance EGD. Sedative agents were used in 41.3% of the patients during EGD. The incidence rates of CCV adverse events with and without sedation were 173.6/10,000 and 315.4/10,000, respectively. Between sedative agent users and nonusers based on propensity score matching (28,008 pairs), there were no significant differences in the occurrence of 14-day CCV, cardiac, cerebral, and other vascular adverse events (2.28% vs 2.22%, p=0.69; 1.44% vs 1.31%, p=0.23; 0.74% vs 0.84%, p=0.20; 0.10% vs 0.07%, p=0.25, respectively).
Conclusions:
Sedation during surveillance EGD was not associated with CCV adverse events in patients with GC. Therefore, the use of sedative agents may be considered in patients with GC during surveillance EGD without excessive concerns about CCV adverse events.
... The estimated overall prevalence of acquired methemoglobinemia was 0.035% during a retrospective review, and the incidence was much higher in hospitalized patients than in procedures performed outpatient (13.7 versus 0.14 cases per 10,000 procedures, respectively) [2]. The incidence of methemoglobinemia may be higher with benzocaine-containing products; nine out of 2,221 patients who received 20% benzocaine spray suffered clinically significant methemoglobinemia, while a comparison group of 22,210 patients who received 4% lidocaine spray had zero incidences of methemoglobinemia [3]. Another study estimated the incidence of methemoglobinemia at 1 in 7000 when benzocaine-containing products are used, but the exact incidence is unknown [4]. ...
A 53-year-old female with a history of rheumatoid arthritis presented with acute-on-chronic shortness of breath. She had severe lung disease secondary to chronic obstructive pulmonary disease (COPD) and recurrent pneumonia. She was found to have recurrent methemoglobinemia and presented to the hospital with refractory hypoxemia. She was given intravenous (IV) methylene blue, and transfused 2 units of packed red blood cells. Her methemoglobin levels again trended up during hospitalization and after identifying and discontinuing the offending agent, an over-the-counter (OTC) benzocaine gel, her methemoglobin level was normalized and she never had a recurrence. The severity of presentation from methemoglobinemia is increased in patients with anemia, heart disease, and pulmonary disease.
... 12,13 Sedation practices have since improved though this may not have improved safety 14 and the population undergoing endoscopy has changed with increasing age and comorbidity, 15 so updated measures are needed. More recent studies suggest that respiratory adverse outcomes are still increased following day-case gastroscopies, particularly in those with existing respiratory disease, 8,16 but can be criticised either for their limited size, or for reliance upon the report of complications back to endoscopists after discharge. Neither of these studies provides data to permit the estimation of risks stratified by age and comorbidity. ...
... or are only secondary care based and so will have missed events presenting in primary care.29 Nevertheless, our study concurs with the available literature in identifying an important increased risk of adverse events after endoscopy. For example, a 1% rate of hospital admission with events related to endoscopic procedures has previously been shown in a study which observed that only 22% of these were captured by the standard reporting of endoscopic complications.16 This study though was from a single centre and therefore examined far lower numbers of procedures than does the current study. ...
Aim
To determine the excess of acute medical contacts following a day‐case diagnostic gastroscopy.
Methods
Cohort study using English linked primary, secondary care and death registry electronic health data. We included 277,535 diagnostic day‐case gastroscopies in 225,304 people between 1998 and 2016 and followed up for 30 days. 1,383,535 30‐day periods without a gastroscopy within 991,249 people frequency matched on year, gender and decade of birth. Non‐cancer deaths, emergency non‐cancer admissions and cardio, vascular or respiratory (CVR) primary care consultations were identified and adjusted for each other as competing risks. Outcomes related to possible indications for gastroscopy were censored.
Results
5.1% of day‐case diagnostic gastroscopies were followed by emergency hospital admission, 0.4% for a CVR diagnosis. Adjusted for age, sex, morbidity, time trends, indications and competing risks, there was a 0.1% excess of CVR‐related hospital admissions compared to controls. This reduced to 0.05% (95% confidence interval 0.04–0.06%) in people under 40 years without morbidity and increased to 1.1% (0.6%–1.6%) in people over 90 years with high comorbidity. Similarly, by 30 days, 3.8% had a primary care consultation for a CVR problem, with an excess after adjustment ranging from 0.13% (0.11%–0.16%) to 0.31% (0.14%–0.50%). Overall numbers needed to harm ranged from 1 in 294 gastroscopies to 1 in 67 gastroscopies.
Conclusions
There was an excess of vascular and respiratory events associated with a diagnostic gastroscopy. In younger patients, this risk manifested as an increase in primary care consultations while in older patients there was an increase in emergency hospital admissions.
... 5 Comprehensive data on adverse outcomes after GI endoscopies are limited, because current understanding relies primarily on self-report or findings based on convenience samples. [9][10][11] Outpatient GI endoscopies are increasingly being performed in ambulatory surgery centers (ASCs). These facilities specialize in surgical and diagnostic procedures that do not require an overnight stay and may provide the same services as hospital outpatient departments (HOPDs) at lower cost. ...
... Although some studies have examined adverse outcomes after colonoscopies or EGDs performed in ASCs, this research is primarily limited to experiences of a single facility, self-reporting by providers, or among a specific patient population. [9][10][11]18,19 Only 2 studies have examined adverse outcomes after colonoscopies or EGDs performed in ASCs at the population level. Both concluded that need for hospitalbased acute care for postprocedure adverse outcomes after these frequently performed GI endoscopies was more common than previously believed. ...
... 54 However, our data do not allow identifying moderate sedation or distinguishing sedationrelated cardiopulmonary events from irrelevant cases. Moreover, studies, including ours, examining both EGD and colonoscopy document a higher prevalence of unplanned hospital use after scheduled outpatient EGD, 9,20 implying a greater need for good clinical triage. There is evidence that most EGD is performed with patients under sedation, and cardiopulmonary adverse events related to sedation or anesthesia are the most common adverse event. ...
Background and aims:
Outpatient GI endoscopy has been shifting from hospital outpatient departments (HOPDs) to ambulatory surgery centers (ASCs) in recent years. However, evidence on whether patient outcomes after endoscopic procedures are comparable across settings is limited. This study compares the incidence of unplanned hospital visits after GI endoscopy performed in ASCs versus HOPDs.
Methods:
We conducted a retrospective cohort study examining unplanned hospital visits after outpatient GI endoscopy performed in Massachusetts during 2014 to 2017 using Massachusetts All-Payer Claims Database and Medicare fee-for-service claims. We identified screening colonoscopy, nonscreening colonoscopy, and esophagogastroduodenoscopies (EGDs) performed in ASCs or HOPDs and estimated unplanned hospital visit rates within 7 and 30 days after these procedures. To compare rates between ASCs and HOPDs, we constructed procedure-specific, propensity score-matched samples and used multilevel logistic regressions adjusting for patient, procedure, and facility characteristics.
Results:
Seven-day unplanned hospital visit rates were 10.6, 18.3, and 38.9 per 1000 procedures for screening colonoscopy, nonscreening colonoscopy, and EGD, respectively, with significant variation across facilities. ASC patients consistently had fewer postprocedure hospital encounters. The relative risk of having 7-day hospital visits after screening colonoscopy performed in ASCs was .88 (95% confidence interval [CI], .79-.98) compared with HOPDs. The estimates were .84 (95% CI, .75-.94) for nonscreening colonoscopy and .57 (95% CI, .50-.65) for EGD. Thirty-day visits showed similar patterns.
Conclusions:
Unplanned hospital visits after outpatient GI endoscopy were not uncommon. However, ASC patients consistently had less frequent hospital-based acute care encounters, indicating that GI endoscopy could be performed safely in ASCs for select patients.
... Nonetheless, the facility should maintain a careful selection process for appropriate patients to be performed in these outpatient facilities. Poor patient or procedure selection can result in unwanted admission to an affiliated hospital 26,27 . ...
... They found that the incidence of hospital visits related to endoscopic procedures were 2-fold to 3-fold higher than the previous estimations. 3 If this is indeed accurate, we might be significantly underestimating AEs not only for high-risk procedures, such as ERCP, but also for routine procedures (upper endoscopies and colonoscopies). ...
... The mean costs associated with postprocedural hospital presentations were US$1403 per ED visit and US$10 123 per hospitalisation. 7 Patient inconvenience, hours absent from work and personal and procedural costs associated with endoscopy further highlight the need for an efficient and inexpensive alternative. ...
Background
The endoscopic appearance of oesophageal varices determines the need for prophylaxis. However, as the point prevalence of varices is low (25%), the majority of surveillance endoscopies are unnecessary and costly. Narrow diameter,ultrathin (UT) endoscopes are more tolerable than conventional upper gastrointestinal (UGI) endoscopes and can be used without sedation. We hypothesised that unsedated UT endoscopy for variceal surveillance could be implemented during the routine outpatient clinic visit allowing accurate diagnosis of varices and the timely provision of prophylaxis.
Methods
Patients with cirrhosis awaiting surveillance endoscopy were identified. UT endoscopy was scheduled during routine clinic review at the same time as ultrasound surveillance for hepatocellular carcinoma. UGI endoscopy was performed unsedated using the E.G Scan II disposable endoscope. Varices were graded using the modified Paquet classification. Video recordings of procedures were reviewed by blinded assessors and agreement was assessed using the kappa statistic.
Results
40 patients (80% male) underwent unsedated UT endoscopy. All procedures were successful and tolerated well in 98% of cases. Median procedure time was 2 min (IQR 1–3). Varices were found in 37.5% (17.5% grade 1 and 20% grade 2). Patients with grade 2 varices were prescribed non-selective beta blockers at the clinic appointment. Kappa statistic for the finding of any varices was 0.636 (p=0.001) and 0.8–1.0 for diagnosis of grade 2 varices (p<0.0001).
Conclusions
Outpatient unsedated ultrathin endoscopy in patients with cirrhosis is accurate, safe and feasible. This integrative care model is convenient, particularly for regional communities, and is likely to result in significant cost savings associated with variceal surveillance.
... Rarely, colonoscopy results in serious complications including bleeding and perforation. In contrast, mild adverse events occur in up to one-third of patients who may experience minor complaints including abdominal pain, bloating, and nausea following colonoscopy [12][13][14][15][16][17][18]. While some studies show that colonoscopy for adults over age 75 is safe, high yield, and cost-effective, others cite a higher risk of postprocedural complications and a limited mortality benefit [19][20][21][22][23][24][25][26][27]. ...
... In this study, we examined the association between age and unplanned ED visit and hospitalization within 7 days of outpatient colonoscopy. Overall, the ED visit rate following screening or surveillance colonoscopy was low (0.62%), which is in line with prior data [16,[32][33][34]. The most common complaints were abdominal pain and gastrointestinal bleeding. ...
Background
The age to stop screening or surveillance colonoscopy is not well established, and unplanned hospital use after colonoscopy in the elderly is not well understood.
Aims
To evaluate unplanned emergency department (ED) visits and hospitalization in patients over 75 within 7 days of outpatient colonoscopy.
Methods
In this retrospective, single-center, cohort study, we reviewed outpatient screening or surveillance colonoscopies in patients ≥ 50 in a tertiary care academic medical center or affiliated facility between January 2008 and September 2013. Colonoscopies were divided by age based on USPSTF recommendations. The rate of ED visits and hospitalizations per colonoscopy for each age-group was determined. Predictors of ED visit and hospitalization were assessed through univariate and multivariate logistic regressions, and mortality following colonoscopy was evaluated using Kaplan–Meier analysis.
Results
A total of 30,409 colonoscopies were performed in 27,173 patients (51% male) by 40 endoscopists. ED visits occurred after 188 colonoscopies (0.62%). Age over 75 years was independently associated with ED visit (OR 1.58, 95% CI 1.05–2.37, p = 0.027) and hospitalization (OR 3.7, 95% CI 2.03–6.73, p < 0.001) within 7 days of colonoscopy. Higher number of medication classes, recent ED visit, polypectomy, and endoscopic mucosal resection were also independent variables associated with ED utilization after procedure. The mortality rate at the end of the follow-up (median 4.4; IQR 2.7–6 years) was 1.9, 8.6, and 15.8% for the age-groups 50–75, 76–85, and > 85 years, respectively.
Conclusion
Patients over age 75 are 1.6 times as likely to use the ED and 3.7 times as likely to be hospitalized after colonoscopy. Further prospective studies are needed to assess the risk/benefit of nondiagnostic colonoscopy in geriatric patients.
