Gastroscopic characterisation and prevalence of gastric ulcer syndrome in working mules in Colombia

BACKGROUND

The existing literature does not contain information about the prevalence of gastric ulcers in mules, and on the potential associations between the presence of ulcers and work load, work type, diet, sex, age and body condition score (BCS).

OBJECTIVE

To estimate the prevalence and factors associated with mule gastric ulcer syndrome (MGUS) and evaluate its distribution in both mule squamous gastric disease (MSGD) and mule glandular gastric disease (MGGD) mucosa in a population of mules in Colombia.

STUDY DESIGN

Observational, cross-sectional.

METHODS

A total of 97 clinically healthy mules of different ages and locations in the province of Antioquia (Colombia) were included in this study. The mules were involved in agricultural activities (i.e., riding, pack and ranch mules) at the time of the study. The animals underwent gastroscopic evaluation, and ulcer scores from 0 to 4 were assigned based on severity, with scores ≥2 indicating clinical relevance. The presence or absence of ulcer in the squamous and/or glandular region of the stomach was recorded. Data related to work type, work load and diet, as well as sex, age and BCS were recorded for each mule. Pearson's chi-square test was used to determine the association between the outcomes and explanatory variables of the study (p ≤ 0.05). The results of the risk estimations were presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The frequency of MGUS in the study population was 42%. Most of the lesions were located in the squamous region of the stomach (27%), mainly in the margo plicatus, and 20% were located in the glandular region, mainly in the fundus and pyloric antrum. Six animals showed lesions in both squamous and glandular regions. Work load was the only variable associated with the presence of MGUS (OR: 1.98; 95% CI: 0.49-0.96) and MSGD (OR: 1.78; 95% CI: 0.36-0.67). Nevertheless, the findings did not provide any significant risk assessment result, nor did they reveal any significant interactions among the other variables.

MAIN LIMITATIONS

This study used convenience sampling from a limited geographic region, and multivariate analysis was not performed, one of the exclusion criteria was the use of nonsteroidal anti-inflammatory drugs, which means that the effect of these drugs can no longer be evaluated.

CONCLUSIONS

MGUS occurs in mules subjected to agricultural work, the risk factors associated with EGUS do not appear to be significant in mules and other equids subjected to the same conditions, in this region. Further research is needed to define the differential dynamics of MGUS in comparison with the findings in horses.

Ovarian serous carcinoma with stomach metastasis: a rare case report and literature review

Ovarian cancer is a common tumor among women. It is often asymptomatic in the early stages, with most cases already at stage III to IVE at the time of diagnosis. Direct spread and lymphatic metastasis are the primary modes of metastasis, whereas hematogenous spread is rare. An initial diagnosis of ovarian cancer that has metastasized to the stomach is also uncommon. Therefore, clear treatment methods and prognostic data for such metastasis are lacking. In our hospital, we encountered a patient with an initial imaging diagnosis of a gastric tumor and a history of an ovarian tumor with endoscopic abdominal metastasis. Based on the characteristics of the case, the two tumors were considered to be the same. After chemotherapy, a partial response was observed in the stomach and pelvic lesions, suggesting the effectiveness of the treatment. Through three treatments of recurrence, gastroscopy confirmed the stomach to be a metastatic site. Therefore, determining the primary source of advanced tumors is crucial in guiding treatment decisions. Clinicians must approach this comprehensively, relying on thorough evaluation and personal experience.

Endoscopic management of gastric ectopic pancreas with repeated ulcerations and bleeding: A case report

A 25-year-old man was referred to our center for investigation of a gastric submucosal tumor and an ulcer that had developed on its oral side. Endoscopic ultrasonography findings suggested the presence of an ectopic pancreas, and treatment with an oral proton pump inhibitor was planned for the ulcer. Over the subsequent 3 years, the patient endured recurring epigastric pain and episodes of passing black stools. Emergency endoscopy revealed that the morphology of the gastric submucosal tumor had transformed into a pedunculated polyp-like morphology with a bleeding ulcer at the apex of the lesion. Endoscopic hemostasis using hemostatic forceps was performed. However, the patient continued to pass black stools. In light of the persistent symptoms and unique morphology of the lesion, endoscopic resection was attempted as a curative approach. The lesion was excised by hot snare polypectomy. Post-treatment, the patient exhibited no signs of recurrence, marking a successful resolution. Three months later, a gastroduodenal endoscopy showed that the excised site had undergone scar formation without recurrence of the lesion. This case holds significant clinical value as it demonstrates the efficacy of a minimally invasive treatment strategy in managing repeated bleeding ulcerations of an ectopic pancreas, ultimately achieving a complete cure.

Gastroduodenitis Associated with Active Ulcerative Colitis Treated with Infliximab: Different Clinical Course in the Colon and Gastroduodenal Lesions

A 29-year-old man with severe ulcerative colitis and gastroduodenitis was initially treated with oral mesalamine and high-dose intravenous steroid therapy; however, his epigastralgia and vomiting did not improve. After initiating infliximab, the patient experienced prompt improvement in symptoms and inflammation. Although steroids were effective for the colon, they proved ineffective for gastroduodenal lesions, highlighting the necessity for molecular-targeted agents, such as infliximab, in these cases. The timing for administering such agents should be carefully considered.

High-Flow Nasal Oxygen versus Conventional Nasal Cannula in Preventing Hypoxemia in Elderly Patients Undergoing Gastroscopy with Sedation: A Randomized Controlled Trial

Background: We aimed to compare the prevention of hypoxemia using High-flow nasal oxygen (HFNO) or regular nasal tubing (CNC) in elderly patients undergoing gastroscopy with sedation. Methods: This study was a prospective, randomized, controlled trial conducted at a single center. We included elective patients aged 65 and above who were undergoing gastroscopy with sedation. In the intervention group (HFNO), we set the oxygen flow rate to 60 liters per minute with an oxygen fraction (FiO2) of 0.6, while in the control group (CNC), it was 6 liters per minute. The primary outcome was the occurrence of hypoxemia (defined as Spo2 < 90%). Results: A total of 125 participants were enrolled (HFNO group: n = 63; CNC group: n = 62). The occurrence of hypoxemia was found to be significantly lower in the HFNO group compared to the CNC group (3.2% vs. 22.6%, p = 0.001). Additionally, a significantly shorter duration of low oxygen levels was observed in the HFNO group [0.0 seconds (0.0-13.0)] compared to the CNC group [0.0 seconds (0.0-124.0), p<0.001]. Moreover, a higher minimum Spo2 value was achieved in the HFNO group [99.0% (98.0-100.0) vs. 96.5% (91.0-99.0), p < 0.001], and a shorter recovery time was recorded [0.5 minutes (0.0-0.5) vs. 0.5 minutes (0.0-1.0), p = 0.016] in comparison to the CNC group. There were no differences in terms of comfort level [0 (0-4) vs. 0 (0-5), p = 0.268] between the two groups. Conclusions: The HFNO system was determined to be a safe and highly effective method for oxygen delivery, leading to a reduction in the occurrence of hypoxemia in elderly patients undergoing gastroscopy with sedation. It is recommended that HFNO be considered as the standard approach for management in this population.

Assessing wound complications in gastroscopy with Streptomyces protease enzyme combined with Shutai

Current gastroscopy practices necessitate a balance between procedural efficiency and patient safety. It has been hypothesized that increasing procedure outcomes through the use of Streptomyces protease enzyme and Shutai is possible; however, precise nature of any potential adverse reactions and complications remains unknown. In Zhanjiang, China, 213 patients undergoing gastroscopy participated in this controlled trial. The subjects were allocated at random into two groups: control and treatment. The treatment group was administered topical Streptomyces protease enzyme and intravenous Shutai. Using chi-square and t-tests, information regarding patient demographics, adverse reactions, wound healing, procedure duration, distress levels, and satisfaction was gathered and analysed. The demographic and medical history characteristics of the groups were comparable. There was a greater prevalence of modest immediate reactions in the treatment group (p < 0.05), whereas there were no significant variations observed in delayed reactions and long-term complications (p > 0.05). The treatment group exhibited superior efficiency metrics, including shorter durations for diagnosis, procedure completion and recuperation (p < 0.05). The treatment group exhibited significantly higher patient satisfaction scores (p < 0.05). The incorporation of Streptomyces protease enzyme and Shutai into gastroscopy procedures resulted in significantly enhanced level of procedural efficacy and patient contentment while not introducing an additional risk of long-term complications. The increase in moderate immediate reactions that have been observed requires additional research in order to determine their clinical significance. Although these agents present a possible progression in the field of gastroscopy, their application should be tempered by the immediate adverse reactions that have been documented.

An Investigation into the Characteristics and Distribution Patterns of Diseases Detected via Gastroscopy in Northern Xinjiang, China

Objective

The aim of this study is to examine the distribution and features of gastroscopy in northern Xinjiang, a province in China.

Methods

We included a group of 895 patients diagnosed with digestive diseases at Urumqi Friendship Hospital and analyzed their gastroscopic results and baseline data.

Results

Among patients aged 12 to 86 years in the specified region, females exhibited a heightened susceptibility to esophageal-gastrointestinal and intestinal disorders compared to males. The mean age for chronic gastritis onset was determined to be 54.79 years. In the context of esophageal-gastric-intestinal disorders, the distribution across various ethnic groups manifested as follows: the Han, Uygur, Hui, and Kazakh populations comprised 53.97%, 23.91%, 7.15%, and 3.46%, respectively. Through principal component-based dimension reduction analysis, we identified chronic non-atrophic gastritis with erosive gastritis, duodenal bulb inflammation, and chronic non-atrophic gastritis (predominantly in the gastric antrum) as pivotal factors contributing to differences in hiatal hernia. Multiple linear regression models were established for different ethnic groups, duodenal bulb inflammation, and hiatal hernia by age. The results revealed a heightened risk of duodenal bulb inflammation (P < 0.01) in Han, Kazakh, Hui, Mongolian, and Uygur women, while the risk of hiatal hernia exhibited a positive correlation with age (P = 0.001).

Conclusion

Among patients undergoing gastrointestinal examinations in northern Xinjiang, the most prevalent pathological condition was identified as chronic gastritis. Notably, within this subgroup, the prevalence of duodenal bulb inflammation was found to be greater in women than in men. The ethnic composition within this context encompassed patients from the Han, Kazakh, Hui, and Mongolian ethnic groups. Furthermore, a positive correlation was identified between the incidence of esophageal hiatal hernia and age.

Effects of adding adjuvants to propofol on the post-anesthesia cognitive function in patients undergoing gastroscopy/colonoscopy: a systematic review and meta-analysis

OBJECTIVES

This study aimed to elucidate the effects of propofol plus adjuvants on postoperative cognitive dysfunction (POCD) and patient satisfaction.

METHODS

Studies published up to September 2023 on the Chinese National Knowledge Infrastructure (CNKI), Wanfang Data, Sinomed, PubMed, Embase, Cochrane Library, Web of Science, and Clinictrials.gov websites were searched. Binary summary of results was used for meta-analyses.

RESULTS

We included 18 studies (2691 patients). The combined sedation did not affect the processing speed (ES = 0.02, 95%CI: -0.01, 0.04; I2 = 79.3%, p < 0.001), attention (ES = 0.02, 95%CI: -0.02, 0.05; I2 = 95.0%, p < 0.001), nor working memory (ES = 0.02, 95%CI: -0.03, 0.06; I2 = 94.4%, p < 0.001) in CogState brief battery tool. A significant effect of combined sedation was observed in the domain of visual learning in CogState tool (ES = -0.03, 95%CI: -0.04, -0.02; I2 = 15.8%, p = 0.306). The TDT (ES = 4.96, 95%CI: 2.92, 7.00) indicates that combined sedation would increase error rates in the tests of cognitive function. The DSST (ES = 0.16, 95% CI: -0.44, 0.75) shown that combined sedation does not affect cognitive function. In addition, an insignificant difference in patient satisfaction between combined sedation and propofol alone was observed (ES = -0.03, 95%CI: -0.09, 0.02).

CONCLUSION

The available evidence suggests that propofol combined with adjuvants may affect POCD but not patient satisfaction.

REGISTRATION NUMBER

INPLASY2023110092.

The effective dose of remimazolam in adult gastroscopy

OBJECTIVES

The objectives of this study were to explore the median effective dose (ED50) and the dose required for successful anesthesia in 95% of the patients (ED95) of remimazolam for intravenous anesthesia in adult outpatients undergoing gastroscopy.

METHODS

This pilot study was conducted in patients scheduled to undergo painless gastroscopy at the authors' hospital between March 15, 2022 and March 25, 2022. The ED of remimazolam was determined using the modified Dixon sequential method, using an initial induction dose of 0.2 mg/kg. With successful or failed anesthesia, the remimazolam dose was decreased or increased by 0.05 mg/kg for the next patient, respectively.

RESULTS

Twenty-two patients (43.6 ± 10.5 years of age) were enrolled. During gastroscopy, the remimazolam induction dose was 19.93 ± 2.96 mg (0.2-0.45 mg/kg). Eighteen patients could complete anesthesia with remimazolam alone, and four patients needed propofol to complete anesthesia. The induction time after the injection of remimazolam was 20.8 ± 8.4 s, the gastroscopy time was 5.1 ± 1.3 min, and the anesthesia recovery time was 17.5 ± 5.6 min. The ED50 and the ED95 of remimazolam were 0.362 mg/kg (95% confidence interval [CI]: 0.313-0.455 mg/kg) and 0.464 mg/kg (95% CI: 0.403-2.242 mg/kg), respectively. The vital signs of all patients remained within the predefined acceptable limits. No patients required antagonist rescue.

CONCLUSION

The ED50 and ED95 of remimazolam for adult gastroscopy were 0.362 mg/kg and 0.464 mg/kg, respectively. Additional anesthetics might be required during gastroscopy in some patients.

TRIAL REGISTRATION

The trial was registered. The number is ChiCTR2200057446.

Important Recommendations Regarding the Test-and-Treat Strategy for Helicobacter pylori Infection in Children

Helicobacter pylori is a commonly encountered pathogen in medical practice. It causes chronic gastritis in patients of different ages. Many published papers have provided different opinions on whether the test-and-treat strategy for H. pylori infection should be implemented in children. It is critical that the opinion in favor of this strategy was published in Europe, where ESPGHAN/NASPGHAN guidelines have not recommended the use of test-and-treat strategy for H. pylori in children. Herein, I propose my opinion regarding this debate using 4 main points. First, this strategy should be implemented in areas where its benefits outweigh the associated risks. Thus, if it is not tailored to the locality, the results of the test-and-treat strategy for H. pylori in children may be erroneous. Second, the association between H. pylori infection and other diseases such as asthma and other allergic diseases should not be factored in when considering the test-and-treat strategy. This is because these diseases are associated with H. pylori noninfection and not with its posteradication status. Third, there is evidence that H. pylori infection can significantly alter children's intestinal microbiota. Finally, gastroscopy should not be performed in all H. pylori-positive children, particularly if the drug susceptibility test is not available. In the near future, it will be possible to easily conduct drug susceptibility tests for H. pylori using fecal samples. I believe that this report may expand the test-and-treat strategy for children infected with asymptomatic H. pylori outside of Japan and prevent not only gastric cancer but also minor diseases such as iron deficiency anemia, chronic idiopathic thrombocytopenic purpura, and failure to thrive. Pediatricians are responsible for keeping children healthy not only during childhood but also in adulthood. Thus, even if there are only a few H. pylori-related diseases and no severe cases in children, it is necessary to take early measures to prevent problems (eg, incidence of gastric cancer) in adulthood.

Gastro-BaseNet: A Specialized Pre-Trained Model for Enhanced Gastroscopic Data Classification and Diagnosis of Gastric Cancer and Ulcer

Most of the development of gastric disease prediction models has utilized pre-trained models from natural data, such as ImageNet, which lack knowledge of medical domains. This study proposes Gastro-BaseNet, a classification model trained using gastroscopic image data for abnormal gastric lesions. To prove performance, we compared transfer-learning based on two pre-trained models (Gastro-BaseNet and ImageNet) and two training methods (freeze and fine-tune modes). The effectiveness was verified in terms of classification at the image-level and patient-level, as well as the localization performance of lesions. The development of Gastro-BaseNet had demonstrated superior transfer learning performance compared to random weight settings in ImageNet. When developing a model for predicting the diagnosis of gastric cancer and gastric ulcers, the transfer-learned model based on Gastro-BaseNet outperformed that based on ImageNet. Furthermore, the model's performance was highest when fine-tuning the entire layer in the fine-tune mode. Additionally, the trained model was based on Gastro-BaseNet, which showed higher localization performance, which confirmed its accurate detection and classification of lesions in specific locations. This study represents a notable advancement in the development of image analysis models within the medical field, resulting in improved diagnostic predictive accuracy and aiding in making more informed clinical decisions in gastrointestinal endoscopy.

Hypereosinophilic syndrome presenting as eosinophilic gastroenteritis exacerbated by clopidogrel bisulphate

Clopidogrel is a widely prescribed prodrug with antithrombotic activity that functions by irreversibly inhibiting the P2Y12 receptors on platelets; nevertheless, drug-induced eosinophilia from this drug is rarely reported. An 81-year-old man was diagnosed with cerebral infarction 2 months earlier and was admitted to our hospital with rash, fever, wheezing, and stomach discomfort after being initiated with clopidogrel treatment. Based on his medical history, chest CT, and gastroscopy, we diagnosed him with clopidogrel-induced hypereosinophilic syndrome. After discontinuation of clopidogrel, the eosinophilia and symptoms improved. In cases of drug-induced eosinophilia, it is important to obtain a detailed medical history.

Gastroscopy for dyspepsia: Understanding primary care and gastroenterologist mental models of practice: A cognitive task analysis approach

Background

Gastroscopy to investigate dyspepsia without alarm symptoms rarely results in clinically actionable findings or sustained health-related quality-of-life improvements among patients aged 18-60 years and is, therefore, not recommended. Despite this, referrals for and performance of gastroscopy among this patient population remain high. The purpose of this study was to understand family physicians' and gastroenterologists' mental models of dyspepsia and the drivers behind referring or performing gastroscopy.

Methods

Cognitive task analysis routine critical decision method interviews with family physicians (n = 8) and gastroenterologists (n = 4).

Results

Family physicians and gastroenterologists hold rich mental models of dyspepsia that rely on sensemaking; however, gaps in information continuity affect their ability to plan and coordinate patient care. Drivers behind decisions to refer or perform gastroscopy were: eliminating risk for serious pathology, providing reassurance, perceived preference by patients to receive information and reassurance from gastroenterologists, maintaining relationships with patients, and saving costs to the health system.

Conclusions

Family physicians refer for dyspepsia when they are seeking support from gastroenterologists, they believe that alternative factors may be impacting the patient's health or view it as a cost-saving measure. Likewise, gastroenterologists perform gastroscopy for dyspepsia when they perceive it as a cost-saving measure, they want to support their primary care colleagues and provide their colleagues and patients with reassurance. An improved degree of communication between speciality and primary care could allow for continuity in the transfer of information about patients and reduce referrals for dyspepsia.

U-Net deep learning model for endoscopic diagnosis of chronic atrophic gastritis and operative link for gastritis assessment staging: a prospective nested case-control study

Background

The operative link for the gastritis assessment (OLGA) system can objectively reflect the stratification of gastric cancer risk in patients with chronic atrophic gastritis (CAG).

Objectives

We developed a real-time video monitoring model for the endoscopic diagnosis of CAG and OLGA staging based on U-Net deep learning (DL). To further validate and improve its performance, we designed a study to evaluate the diagnostic evaluation indices.

Design

A prospective nested case-control study.

Methods

Our cohort consisted of 1306 patients from 31 July 2021 to 31 January 2022. According to the pathological results, patients in the cohort were divided into the CAG group and the chronic non-atrophic gastritis group to evaluate the diagnostic evaluation indices. Each atrophy lesion was automatically labeled and the atrophy severity was assessed by the model. Propensity score matching was used to minimize selection bias.

Results

The diagnostic evaluation indices and the consistency between OLGA staging and pathological diagnosis of the model were superior to those of endoscopists [sensitivity (89.31% versus 67.56%), specificity (90.46% versus 70.23%), positive predictive value (90.35% versus 69.41%), negative predictive value (89.43% versus 68.40%), accuracy rate (89.89% versus 68.89%), Youden index (79.77% versus 37.79%), odd product (79.23 versus 4.91), positive likelihood ratio (9.36 versus 2.27), negative likelihood ratio (0.12 versus 0.46)], areas under the curves (AUC) (95% CI) (0.919 (0.893-0.945) versus 0.749 (0.707-0.792), p < 0.001) and kappa (0.816 versus 0.291)].

Conclusion

Our study demonstrated that the DL model can assist endoscopists in real-time diagnosis of CAG during gastroscopy and synchronous identification of high-risk OLGA stage (OLGA stages III and IV) patients.

Trial registration

ChiCTR2100044458.

Combination of gastroscopy and fibro‑bronchoscopy facilitates removal of incarcerated fish bone in the esophagus: A case report

Esophageal foreign body impaction is a notable clinical emergency. If the high-risk esophageal foreign bodies are not removed in time, life-threatening complications, such as perforation, infection and injury to the vessels, may occur. In the present study, the case of a patient experiencing a foreign body sensation in the throat after ingesting a fish bone by mistake is presented. A high risk of impending arterial puncture was confirmed using thoracic CT and thoracic aorta CT angiography scanning. The ends of the fish bone were first confirmed using a fibro-bronchoscopy light source passing through the bronchial and esophageal walls, before biopsy forceps were used to successively free the thoracic aorta and bronchial ends under gastroscopy. Finally, the fish bone was safely removed using a combination of gastroscopy and the rarely used fibro-bronchoscopy, and the patient recovered well after standard care. In certain cases of foreign bodies, it is necessary to use multiple strategies in a timely manner according to the type and location of the ingested foreign body.

Effectiveness of the Sellick maneuver for painless gastroscopy in patients with esophageal hiatal hernia: A randomized, self‑control trial

The Sellick maneuver is used for endotracheal intubation to prevent the occurrence of gastroesophageal reflux. The aim of the present study was to observe the effect of the Sellick maneuver on safety, esophageal closure status, gastric mucosal fold extension status, and positive detection rate of lesions in patients with esophageal hiatal hernia under painless gastroscopy. A total of 40 patients with esophageal hiatal hernia who underwent painless gastroscopy were screened for the use of the Sellick maneuver, in which the operator applied pressure to the cervical cricoid cartilage during the examination. The status of esophageal closure at the are pressed, examination time, gastric mucosal fold extension score, positive rate of lesion detection, and reflux of gastric juice or gastric contents, amongst other parameters were assessed. After using the Sellick maneuver, the state of esophageal closure during gastroscopy was significantly better than the no-Sellick maneuver group (P<0.05), and the extension scores of the greater curvature folds of the gastric body, the lateral folds of the lesser curvature of the gastric body, and the mucosal folds of the fundus were significantly higher than that of the no-Sellick maneuver (all P<0.05). The number of gastric polyps and gastric lesions (gastric ulcers and mucosal hyperplasia, amongst others) examined with the Sellick maneuver was significantly higher than the no-Sellick maneuver group (P<0.01). The Sellick maneuver effectively improved the extension of gastric mucosal folds during gastroscopy in patients with esophageal hiatal hernia, increased the positive detection rate of gastric lesions, and shortened the endoscopy time.

Comparison of 95% effective dose of remimazolam besylate and propofol for gastroscopy sedation on older patients: A single-centre randomized controlled trial

AIMS

Advanced age is an important risk factor for adverse events during procedural sedation. Remimazolam is safe and effective in gastroscopic sedation. However, the ideal dose and application for older patients are not well known. We aim to investigate its 95% effective dose (ED95) for older patients undergoing gastroscopy and to assess its safety and efficacy, with propofol as the comparison.

METHODS

The trial consists of 2 parts, patients aged >65 years and scheduled for outpatient painless gastroscopy were enrolled. In the first part, Dixon's up-and-down methodology was used to determine the ED95 of remimazolam besylate and propofol for gastroscopic insertion, in combination with 0.2 μg/kg remifentanil. In the second part, patients in each group received 0.2 μg/kg remifentanil and ED95 dose of the study drugs for sedation induction, supplemental doses were added to maintain sedation depth when necessary. The primary outcome was the incidence of adverse events. The secondary outcome was the recovery time.

RESULTS

The ED95 of remimazolam besylate and propofol induction were 0.2039 (95% confidence interval 0.1753-0.3896) mg/kg and 1.9733 (95% confidence interval 1.7346-3.7021) mg/kg respectively. Adverse events were reported in 26 (40.6%) patients in the remimazolam group and 54 (83.1%) in the propofol group (P < .0001), whereas the remimazolam group presented a higher incidence of hiccups (P = .0169). Besides, the median time to awakening was approximately 1 min shorter with remimazolam than with propofol (P < .05).

CONCLUSION

For older patients undergoing gastroscopy, the ED95 dose of remimazolam is a safer alternative than propofol when inducing the same sedation depth.

Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study

BACKGROUND

Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms.

METHODS

Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated.

KEY RESULTS

Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype.

CONCLUSIONS AND INFERENCES

Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.

The displaced polymer clamp entered the duodenum causing an abscess: A case report

RATIONALE

The Hem-o-lok clip, made from a nonabsorbable polymer, and its predecessor the metal ligation clip have been used widely for laparoscopic or robot-assisted surgery to ligate the cystic duct after a cholecystectomy, to ligate the appendix after an appendectomy, or control hemorrhage or on occasion to occlude a fistula or enterotomy. Displacement of these ligation clips to distant sites is an extremely rare complication in clinical practice.

PATIENT CONCERNS

The patient is a 67-year old female who sought medical attention for 3 days due to worsening intermittent upper abdominal pain and poor appetite. Gastroscopy showed both an ulcer and the presence of a foreign object embedded in the anterior wall of the duodenal bulb, consistent with what looked like a polymer-based ligation clip. After removal of the foreign body, which turned out to be a remnant of the polymer clip, no further pus was seen, but fresh granulomatous tissues were seen at the base.

DIAGNOSES

a polymer-based clip-induced duodenal bulb erosion with a local contained enterically draining abscess.

INTERVENTIONS

The patient recovered after removing foreign bodies under gastroscopy and receiving anti infection treatment.

OUTCOMES

The patient recovered after removing foreign bodies under gastroscopy and receiving anti infection treatment.

LESSONS

In laparoscopic cholecystectomy, attention should be paid to the correct surgical techniques, possibly by decreasing the number of such clips used or considering use of absorbable clips, ligature wires, ligation with absorbable suture material, or ultrasonic resection, all of which can be used for clipless cholecystectomy.

The adoption of artificial intelligence assisted endoscopy in the Middle East: challenges and future potential

The use of artificial intelligence (AI) in endoscopy has shown immense potential to enhance diagnostic accuracy, streamline procedures, and improve patient outcomes. There are potential uses in every field of endoscopy, from improving adenoma detection rate (ADR) in colonoscopy to reducing read time in capsule endoscopy or minimizing blind spots in gastroscopy. Indeed, some of these systems are already licensed and in commercial use across the world. In the Middle East, where healthcare systems are rapidly evolving, there is a growing interest in adopting AI technologies to revolutionise endoscopic practices. This article provides an overview of the advancements, potential opportunities and challenges associated with the implementation of AI in endoscopy within the Middle East region. Our aim is to contribute to the ongoing dialogue surrounding the implementation of AI in endoscopy and consider some of the factors that are particularly relevant in the Middle Eastern context, including the need to train the models for local populations, cost and training, as well as trying to ensure equity of access for patients. It provides valuable insights for healthcare professionals, policymakers, and researchers interested in leveraging AI to enhance endoscopic procedures, improve patient care, and address the unique healthcare needs of the Middle East population.

Availability of CT, MRI, and endoscopy procedures for Polish individuals with morbid obesity: cross-sectional telephone survey study

Purpose

The rise in morbid obesity presents diagnostic challenges in computed tomography (CT), magnetic resonance imaging (MRI), and endoscopy. Research on the availability of these procedures for people with extreme obesity is limited. We aimed to analyse the accessibility of CT, MRI, and endoscopy procedures for people with extreme obesity in a significant sample of facilities serving in the Polish public healthcare system.

Material and methods

A telephone-based survey was conducted on healthcare facilities offering CT, MRI, or endoscopy procedures, identified using the Polish National Health Fund (NFZ) API. A refined questionnaire was utilized after a pilot study to collect details on the equipment's weight and diameter capacities, among other parameters. Of the initial 312 facilities sampled, 195 were eligible and successfully contacted, representing 9.4% of the facilities offering the procedures in the NFZ database.

Results

Of the 195 facilities, 86.4% of CT departments knew their scanner's maximum weight, 57.6% its diameter; 76.5% of MRI departments recognized their scanner's weight, and 59.2% its diameter, while 77.3% of endoscopy departments were aware of their maximum weight capacity. Approximately 28% of CT, 5% of MRI, and 39% of endoscopy departments could perform the procedure if the patient's weight was over 200 kg. Facilities knowledgeable about CT's maximum diameter and MRI's maximum weight often provided private CT/MRI services.

Conclusions

A significant proportion of Polish facilities providing CT, MRI, and endoscopic examinations in the Polish public healthcare system were unaware of their equipment's weight and diameter limits. Merely 5% of the surveyed MRI facilities could potentially accommodate a patient weighing over 200 kg.

Patients at risk for further examination with conventional gastroscopy after undergoing magnetically controlled capsule endoscopy

OBJECTIVE

In this study we aimed to compare the need for further examination with conventional gastroscopy within 1 year after magnetically assisted capsule endoscopy (MCCE) examination between patients with gastrointestinal (GI) symptoms and asymptomatic individuals.

METHODS

After propensity score matching analysis, 372 patients with GI symptoms and 372 asymptomatic individuals who had undergone MCCE at the First Affiliated Hospital of Sun Yat-sen University from January 1, 2019 to December 30, 2020 were retrospectively enrolled. Demographic and clinical characteristics of the participants and their MCCE and gastroscopic findings (performed within 1 year after MCCE) were analyzed.

RESULTS

Fifty-one (6.85%) patients underwent further examination with conventional gastroscopy within 1 year after MCCE. Those with GI symptoms were more likely to undergo conventional gastroscopy than those without (9.95% vs 3.76%, P < 0.001). Polyps were the most common finding of MCCE. The rate of conventional gastroscopy in patients with focal lesions was significantly higher than that in those without focal lesions (P < 0.05). However, such rate did not differ in the different age groups (P = 0.106).

CONCLUSIONS

MCCE is an optimal alternative for gastric examination, especially for large-scale screening of asymptomatic individuals. Patients with GI symptoms or focal lesions detected by MCCE are more likely to seek further examination with conventional gastroscopy for biopsy or endoscopic treatment than those without.

Epidemiology, Risk Factors for Gastric Cancer and Surveillance of Premalignant Gastric Lesions: A Prospective Cohort Study of Central Saudi Arabia

(1) Background: Saudi Arabia (SA) is a country with a low incidence of gastric cancer (GC). In this study, we sought to assess the epidemiology of GC, its clinicopathological profiles, and its association with risk factors as well as to identify premalignant gastric lesions (PGL) and examine neoplastic progression. (2) Methods: This five-year prospective study screened for GC and PGL in asymptomatic Saudi patients, aged 45-75 years (n = 35,640) and living in Al Kharj, Riyadh province in central SA. Those who were positive in a high-sensitivity guaiac fecal occult blood test (HSgFOBT+) and had negative results in colonoscopy offered to undergo upper GI endoscopy (n = 1242). Factors associated with GC were examined. (3) Results: The five-year participation rate was 87% (1080/1242). The incidence rate of GC was 26.9 new cases per 100,000 population per year (9.6 new cases per year/total population at risk-35,640), and it was 8.9 cases per 1000 persons per year among the 1080 subjects with HSgFOBT+ and negative colonoscopy results. The five-year mortality rate was 67% among patients with GC (n = 48), 3.0% among participants in the gastric screening program (n = 1080) and 0.09% among the original population participating in the colorectal screening program (n = 35,640). Intestinal-type adenocarcinoma was the most frequent type (77%), with the tumor most commonly located in the antrum (41%). Overall, 334 participants had PGL, and seven of them (2.1%) showed neoplastic progression to GC during the follow-up. Factors associated with GC were age, Helicobacter pylori (HP) infection, obesity (body mass index BMI > 30), smoking, a diet of salty preserved foods, low income and a family history of GC. (4) Conclusions: The incidence of GC is low in central SA, but screening for PGL and GC among patients with HSgFOBT+ and negative colonoscopy may prevent or result in the early treatment of GC. HP eradication, normal body weight, not smoking and adhering to a healthy diet can reduce the risk of GC. The resulting data provide important input for the improvement of national guidelines.

What is the significance of the Hill classification?

This study aimed to investigate the significance of Hill classification to predict esophagitis, Barrett's esophagus, gastroesophageal reflux disease (GERD) symptomatology, and future prescriptions of proton pump inhibitors in clinical practice. A total of 922 patients (546 women and 376 men; mean age 54.3 [SD 18.4] years) who underwent gastroscopy between 2012 and 2015 were analyzed. Patient questionnaire regarding symptoms were compared with endoscopy findings. A medical chart review was done that focused on the prescription of PPIs, additional gastroscopies, and GERD surgery in a 3-year period before the index gastroscopy and in a 6-year period afterward. In patients naïve to PPI prescriptions (n = 466), Hill grade III was significantly associated with esophagitis (AOR 2.20; 95% CI 1.00-4.84) and > 2 PPI prescriptions 6 year after the index gastroscopy (AOR 1.95; 95% CI 1.01-3.75), whereas Hill grade IV was significantly associated with esophagitis (AOR 4.41; 95% CI 1.92-10.1), with Barrett's esophagus (AOR 12.7; 95% CI 1.45-112), with reported heartburn (AOR 2.28; 95% CI 1.10-4.74), and with >2 PPI prescriptions (AOR 2.16; 95% CI 1.02-4.55). In patients 'non-naïve' to PPI prescription (n = 556), only Hill grade IV was significantly associated with esophagitis, reported heartburn, and with >2 PPI prescriptions. The gastroscopic classification in Hill grades III and IV is important in clinical practice because they are associated with esophagitis, Barrett's esophagus, symptoms of GERD, and prescriptions of PPIs, whereas a differentiation between Hill grades I and II is not.

Chronic atrophic gastritis - An overlooked association with severe vitamin B12 deficiency: A case report and rapid review of literature

Current guidelines recommend surveillance for gastric adenocarcinoma in patients with extensive chronic atrophic gastritis (CAG), which is considered a premalignant condition. Although the association between vitamin B12 deficiency and CAG is well described, the indication for endoscopic investigation is only advised in patients with pernicious anaemia. Our case did not have evidence of autoimmune or H. pylori infection but despite this she had CAG. We suggest considering gastroscopy for severe, unexplained vitamin B12 deficiency, particularly in this patient group.

Ultrasonographic Assessment of Gastric Volume in Fasted Patients Undergoing Gastrointestinal Endoscopy Under Sedation

Purpose

In this prospective observational study, an ultrasonographic measurement of antral cross-sectional area (ACSA) was conducted to evaluate the gastric content and volume as well as to identify high-risk stomach in non-pregnant adult surgical patients adhering to preanesthetic fasting guidelines.

Patients and Methods

Fasted patients undergoing gastrointestinal endoscopy under sedation were included. Ultrasonographic measurements of ACSA were conducted in both semi-recumbent and right lateral decubitus positions before endoscopic procedures. Gastroscopy was employed to guide the measurement of suctioned gastric volume (GV). Ultrasonography was performed to assess gastric contents and identify patients with high-risk stomach. The relationship between ACSA and suctioned GV was also evaluated.

Results

ACSA was evaluated in 736 out of 782 patients. A significant positive correlation was discovered between ACSA in the right lateral decubitus position and suctioned GV, which was more reliable than in the semi-recumbent position. To analyze high-risk stomach with a GV > 100 mL, the cutoff value of ACSA in the right lateral decubitus was found to be 7.5 cm2, with the AUC, sensitivity and specificity of 0.80 (95% CI, 0.76-0.82; P<0.001), 82.4% and 67.3%, respectively. A novel mathematical model based on ACSA to estimate GV in non-pregnant fasted adults was presented.

Conclusion

Ultrasonographic measurement of ACSA can assist anesthesiologists in estimating the risk of pulmonary aspiration of gastric contents during general anesthesia and sedation.

Safety Assessment of an Oral Therapeutic Dose of Firocoxib on Healthy Horses

Firocoxib is a non-steroidal anti-inflammatory drug specifically formulated for veterinary medicine and selectively acts on inhibiting the cyclooxygenase 2 enzyme (COX-2). This study evaluated the possible adverse effects of administering oral therapeutic firocoxib on gastric mucosa, hematological parameters, coagulation cascade, and hepatic and renal biochemistry in healthy horses. Nine clinically healthy Arabian horses, approximately 9 years old, received 0.1 mg/kg of oral firocoxib for 14 days. The gastroscopic examination was conducted 1 day before starting treatment (D0) and two days after the last blood collection (D23). Venous blood samples were obtained for laboratory tests on day 1, immediately prior to the initiation of treatment (D1), after 7 and 14 days of treatment (D7 and D14), and 7 days after the conclusion of treatment (D21. No changes were found in the gastroscopic and hematological tests. Coagulation and serum biochemistry levels remain between these species' average values. However, the increased activated partial thromboplastin time (aPTT) and prothrombin time (PT) indicate reduced blood coagulation capacity, which contradicts the expected effect of treatment with selective COX-2 inhibitors, as these drugs theoretically promote coagulation. Administering firocoxib to horses is safe as it does not cause significant adverse reactions. Therefore, it is a suitable option for managing inflammatory conditions in these animals with attention to an unexpected adverse anti-coagulopathy effect, and further study is warranted.

Comparison of propofol-esketamine versus propofol for anesthesia in gastroscopy: a double-blind, randomized controlled clinical trial

Objective

To compare the effects of propofol-esketamine and propofol in gastroscopy in adults.

Methods

This randomized controlled clinical trial was performed from January 2021 to March 2021. Eighty patients were enrolled and allocated into normal saline group (group N) and esketamine group (group E). The primary outcome was total amount of propofol. Secondary outcomes included incidences of injection pain, involuntary movement, hemodynamic and respiratory adverse events during examination, total examination time, recovery time and postoperative adverse effects.

Results

Total amount of propofol was significantly smaller in group E (101.64 ± 32.64 mg) than in group N (129.55 ± 36.34 mg, p = 0.001). Incidences of injection pain, involuntary movement and hypotension was significantly lower in group E than in group N. Incidences of hypertension and tachycardia was higher in group E than in group N. There was no significant difference in incidences of laryngospasm or hypoxemia, total examination time, recovery time, incidences of postoperative adverse effects between two groups.

Conclusion

Combination of propofol with 0.2 mg/kg esketamine reduced total amount of propofol, provided a more stable hemodynamic status and did not affect recovery time in gastroscopy.

Clinical trial registration

http://www.chictr.org, identifier ChiCTR2100042406.

Sedation with a 1:1 mixture of etomidate and propofol for gastroscopy in hypertensive elderly patients

We hypothesized that the combined use of etomidate and propofol for endoscopic sedation in elderly hypertensive patients could reduce adverse reactions while providing ideal sedation. To validate our hypothesis, we conducted a prospective, randomized, controlled, double-blinded study. A total of 360 elderly hypertensive patients scheduled for gastroscopy at our hospital were enrolled in the study, of whom 328 completed the trial. The patients were randomly assigned to one of three groups: the propofol group (group P), the etomidate group (group E), or the propofol-etomidate combination group (mixed at a ratio of 1:1, group PE). We collected and analyzed the cardiopulmonary effects and side effects in each group. Regardless of the sedation drug used, the systolic blood pressure, mean blood pressure, and heart rate of involved patients were significantly affected. Oxygen desaturation and injection pain were more common in group P compared to groups E (33.6% vs. 14.8%, 31.8% vs. 2.7%, both P < 0.01) and group PE (33.6% vs. 13.6%, 31.8% vs. 6.4%, both P < 0.01). The incidence of myoclonus in the PE group was lower than that in the E group (10.9% vs. 61.2%, P < 0.01). Our results indeed demonstrated that the combined use of etomidate and propofol appeared to maintain cardiopulmonary stability with minimal side effects in older hypertensive patients scheduled for gastroscopy, which further implied that this sedation strategy could be a safe and pain-free option for managing patients undergoing gastroscopy, particularly those at a higher risk of adverse cardiovascular events.

Ultrasound assessment of gastric residual volume in patients over 60 years of age undergoing gastroscopy under sedation: a prospective cohort study

BACKGROUND

We aimed to assess the accuracy of ultrasonographic measurement of the antral cross-sectional area (CSA) in the preprocedural evaluation of gastric contents and volume in fasted patients > 60 yr of age scheduled for gastroscopy under sedation.

METHODS

We included n = 81 patients > 60 yr of age and n = 79 younger controls scheduled to undergo elective gastroscopy in a prospective cohort study. A gastric ultrasound examination was performed to measure the antral CSA in both semisitting and right lateral decubitus (RLD) positions. Afterward, patients were graded using the Perlas qualitative grading scale. The actual gastric volume was endoscopically suctioned. Full stomach was defined as gastric volume > 1.5 mL·kg-1 and/or the presence of solid particles. We constructed receiver operating characteristic curves to determine the accuracy of ultrasonographic measurement of RLD CSA to detect a gastric volume > 1.5 mL·kg-1 and calculated the diagnostic test attributes of RLD CSA for the identification of a gastric volume > 1.5 mL·kg-1 RESULTS: The incidence of full stomach was 8/81 (9.8%) in patients > 60 yr of age and 1/79 (1.2%) in young patients (risk difference, 8.6%; 95% CI, 1.3 to 15.8; P = 0.03). The cut-off value of RLD CSA was 10.4 cm2 for the detection of gastric volume > 1.5 mL·kg-1 in patients > 60 yr of age, with a sensitivity of 75%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 98.6%.

CONCLUSION

Patients > 60 yr of age scheduled for gastroscopy under sedation had a higher incidence of a full stomach detected with ultrasound compared with a younger cohort, which is potentially associated with a higher aspiration risk. We calculated a cut-off value of RLD CSA for detecting gastric volume in patients > 60 yr of age of approximately 10 cm2, which may help to quickly assess patients at risk of aspiration.

TRIAL REGISTRATION

www.chictr.org.cn (ChiCTR2100048994); registered 19 July 2021.

Sedative-sparing effect of acupuncture in gastrointestinal endoscopy: systematic review and meta-analysis

Objective

This study aimed to perform a systematic review and meta-analysis to identify the efficacy of acupuncture therapy (including manual acupuncture and electroacupuncture) performed before or during gastrointestinal endoscopy with propofol as the main sedative, compared with placebo, sham acupuncture, or no additional treatment other than the same sedation.

Methods

A systematic search was performed through PubMed, Embase, Web of Science, Cochrane Library, Chinese Biomedical Databases (CBM), Wanfang database, China National Knowledge Infrastructure (CNKI), SinoMed, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials published before 5 November 2022. Bias assessment of the included RCTs was performed according to Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). Stata16.0 software was used to perform statistical analysis, sensitivity analysis, and publication bias analysis. The primary outcome was sedative consumption, and the secondary outcomes included the incidence of adverse events and wake-up time.

Results

A total of 10 studies with 1331 participants were included. The results showed that sedative consumption [mean difference (MD) = -29.32, 95% CI (-36.13, -22.50), P < 0.001], wake-up time [MD = -3.87, 95% CI (-5.43, -2.31), P < 0.001] and the incidence of adverse events including hypotension, nausea and vomiting, and coughing (P < 0.05) were significantly lower in the intervention group than in the control group.

Conclusion

Acupuncture combined with sedation reduces sedative consumption and wake-up time compared with sedation alone in gastrointestinal endoscopy; this combined approach allows patients to regain consciousness more quickly after examination and lower the risk of adverse effects. However, with the limited quantity and quality of relevant clinical studies, caution must be applied until more high-quality clinical studies verify and refine the conclusions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier: CRD42022370422.

[Esophageal candidiasis as an indicator condition]

Esophageal candidiasis is the most common infectious disease of the esophagus. The diagnosis is based on gastroscopy, and in many cases, biopsy samples should be taken as well. If we do not know of any risk factors for an immunocompromised condition, it is a mutual responsibility to confirm or exclude any potential chronic disease in the background, thus not just the secondary complication but also the primary disease could be treated. Without this knowledge, in many cases, the correct diagnosis may be delayed for months or even years, which may risk the successful treatment. We present the case of a 58-year-old healthy woman without any chronic disease, who was referred to our clinic with dysphagia. Due to her complaints we performed a gastroscopy, upon which advanced esophageal candidiasis was diagnosed, hence she was started on oral systemic antifungal treatment. Although we could not explore any risk factors, further investigations behind the immunocompromised condition revealed a positive immunoserology test for HIV. The take-home message of our case is that in the case of esophageal candidiasis, the cause of immunosuppression must be searched for, of which HIV serology is crucial. Thanks to the prompt and correct diagnosis, we could start the suitable treatment of the underlying disease. Orv Hetil. 2023; 164(22): 878-880.

Efficacy for diagnoses of scirrhous gastric cancer and safety of endoscopic ultrasound-guided fine-needle aspiration: A systematic review and meta-analysis

Scirrhous gastric cancer (SGC) is diagnosed using endoscopy and/or biopsy; however, SGC diagnosis remains challenging owing to its special growth form and morphologic features. Hence, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), which is minimally invasive and has a high proportion of diagnostic tissue, may be an alternative investigative modality for patients with suspected SGC. This systematic review and meta-analysis aimed to identify and evaluate the evidence for the efficacy and safety of EUS-FNA in patients with suspected SGC. We conducted a systematic review using the PubMed (MEDLINE) and Ichushi-Web (NPO Japan Medical Abstracts Society) databases and included all entries in which SGC was evaluated using EUS-FNA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement from the databases' inception to October 10, 2022. The primary outcome was the proportion of SGC diagnosed using EUS-FNA. In addition, we analyzed the proportion of adverse events associated with EUS-FNA. The electronic search identified 1890 studies; overall, four studies met the selection criteria and reported data on EUS-FNA performed on 114 patients with suspected SGC. The overall diagnostic yield of EUS-FNA for SGC was 82.6% (95% confidence interval, 74.6-90.6%) and the statistical heterogeneity was 0% (I ² = 0%), indicating a low heterogeneity. Furthermore, the EUS-FNA diagnostic proportion for SGC lymph node metastasis was 75-100%, indicating a high diagnostic performance. The adverse event rate of EUS-FNA was 0%. EUS-FNA may be an alternative investigation mode for SGC patients with negative esophagogastroduodenoscopy-biopsy results.

Safety and effectiveness of the combination of remimazolam tosilate and propofol in gastroscopy: a multicenter, randomized controlled, single-blind clinical trial

Remimazolam tosilate (RT) is a new short-acting γ-aminobutyric acid A (GABAA) receptors agonist. However, its optimal use mode and dosage still remain unclear. This study aimed to examine the safety and effectiveness of the combination of RT and propofol in gastroscopy. This was a prospective, single-blind, randomized, multicenter, parallel-group study. All eligible 256 patients were randomized into the following 3 groups. Patients were anesthetized with propofol (Group P), RT (Group R) or the combination of RT and propofol (Group RP). The primary efficacy endpoints were: body movement score; satisfaction of gastroscopy doctors; success rate of sedation and effects on sleep status. Sedation induction time, time to be fully alert and adverse events were also recorded. The probability of complete immobility was lower in group R (33.73%) than in group P (86.67%) and RP (83.13%). The rate of doctors' satisfaction was much lower in group R (28.92%) than in group P (77.78%) and RP (72.29%). The success rate of sedation and sleep outcome score has no difference in the three groups. The time to adequate sedation was longer in group RP (77.27 ± 18.63 s) than in group P (64.47 ± 24.36 s), but much shorter than that in group R (102.84 ± 46.43s). The time to be fully alert was shorter in group R (6.30 ± 1.52 min) and RP (6.54 ± 1.13 min) than in group P (7.87 ± 1.08 min). The proportion of sedative hypotension was significantly higher in group P (41.11%) than in group R (1.20%) and group RP (3.61%) (p < 0.001). The incidence of respiratory depression was much higher in group P (17.78%) than in group R (no patient) and group RP (1.2%). The incidence of adverse events was lower in groups R (4.82%) and RP (9.64%) than in group P (31.11%). The combination of RT and propofol takes effect quickly, makes patients alert quickly, provides a sufficient depth of sedation, reduces body movement, does not inhibit circulation and respiratory function, does not affect sleep, and is the preferred mode for gastroscopy doctors and anesthesiologists.

Preoperative clear fluid fasting and endoscopy-measured gastric fluid volume in children

BACKGROUND

In light of new recommendations to shorten clear fluid fasting time before anesthesia, our study aimed at exploring residual fluid volume in the stomach after different fasting times. We intended to perform direct endoscopic aspiration of stomach contents under vision, as part of routine gastroscopy assessment. Hereby we would be able to quantify true residual gastric fluid volume and acidity in children and measure their correlation with fasting times.

METHODS

The study was performed as a single-center, prospective study in pediatric perioperative day care at a university-affiliated tertiary care center. Aspiration of gastric fluid contents was performed in anesthetized children aged 1-18 years undergoing an elective gastroscopy. Recorded data included patient fast time, last meal content, last clear fluid content, and aspirated gastric volume and pH, as well as patient characteristics.

RESULTS

We included 253 gastroscopies, performed in 245 children. Mean fasting time for clear fluids was 6.9 h (range 1 h 40 min - 18 h 35 min) (SD 4.5). Mean age was 9.8 years (SD 5.1) and mean body weight was 33.2 kg (SD 18.7). Mean residual gastric volume was 12 mL (0-90) (SD 13.5) or 0.34 mL/kg (SD 0.37) and mean pH was 1.5 (SD 0.9). No significant correlation was observed between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight (r = -.103, p = .1), nor between clear fluid fasting time and the pH of the residual gastric fluid (r = -.07, p = .3). In more than half of the patients the residual gastric volume was less than 10 mL, unrelated to fasting time.

CONCLUSIONS

In children undergoing gastroscopy, we could not demonstrate any association between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight. Since we did not see a clinically relevant association between clear fluids fasting time and gastric residual volume, this study may support the recommendation to shorten clear fluids fasting time.

Performance evaluation of a novel 14C-urea breath test (solid scintillation) for the diagnosis of helicobacter pylori infection

14C-urea breath tests (UBTs) can be used to diagnose helicobacter pylori (H. pylori) infection. This study aimed to evaluate the accuracy of a solid scintillation 14C-UBT in diagnosing H pylori infection. This open-label, prospective multicenter study enrolled patients who underwent H pylori screening from January 7, 2020, to October 28, 2020, in 3 centers in China. All participants underwent solid scintillation UBT first and then gastroscopy. The rapid urease test and histological examination results were the gold standards (H pylori-positive was defined as the 2 tests being positive; H pylori-negative was defined as both tests being negative). The solid scintillation 14C-UBT involves a scintillation sampling bottle and a 14C-urea capsule. The sampling bottle contains a stack of carbon dioxide-absorbing and scintillation sheets. The test is read using a photomultiplier. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for H pylori infection were evaluated. This study enrolled 239 participants. There were 98 males and 141 females, aged 45.8 ± 11.9 (range: 21-66) years. Thirty-four participants were excluded due to a discrepancy between the rapid urease test and immunohistochemistry examination. Finally, 205 participants were included in the analysis. According to the gold standard, 87 out of 205 (42.4%) participants were H pylori-positive. Compared with the gold standard, the sensitivity, specificity, accuracy, and positive and negative predictive values of the solid scintillation 14C-UBT were 95.4%, 97.5%, 96.6%, 96.5%, and 96.6% for the solid scintillation UBT, respectively. One participant experienced 1 adverse event (AE) (exacerbation of chronic cholecystitis), and the AE eventually improved by itself. The investigators determined that the AE was unrelated to the study device. The noninvasive solid scintillation 14C-UBT has a high diagnostic value for H pylori infection, comparable to the diagnostic value of the gold standard.

All Tangled Up: Meter-Long Gastric Trichobezoar Causing Multiple Intussuscepting Points in an Adult

Gastric trichobezoars are a result of trichophagia secondary to trichotillomania, and can result in severe complications such as perforation or intussusception. We present the case of a 19-year-old female with multiple points of intussusception secondary to a large gastric/small intestine trichobezoar and describe our approach to diagnosis and eventual removal of the bezoar.

Upper Gastrointestinal Endoscopy in Subjects with Positive Faecal Occult Blood Test Undergoing Colonoscopy: Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

The role of gastroscopy to investigate the upper gastrointestinal (UGI) tract in subjects with positive faecal occult blood test (FOBT+) is controversial. We conducted a systematic review and meta-analysis, which aimed to determine the prevalence of UGI lesions in FOBT+ subjects.

METHODS

Databases were searched until April 2022 for studies reporting UGI lesions in FOBT+ subjects undergoing colonoscopy and gastroscopy. Pooled prevalence rates of UGI cancers and clinically significant lesions ((CSL), lesions potentially explaining occult blood loss)), Odds Ratio (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

We included 21 studies, with 6993 FOBT+ subjects. Pooled prevalence of UGI cancers was 0.8% (95%CI0.4-1.6) and UGI CSL was 30.4% (95%CI20.7-42.2), while that of colonic cancers and CSL was 3.3% (95%CI1.8-6.0) and 31.9% (95%CI23.9-41.1), respectively. There was no significant difference in the prevalence of UGI CSL and UGI cancers in FOBT+ subjects with/ without colonic pathology, (OR=1.2, 95%CI0.9-1.6, p=0.137, and OR=1.6, 95%CI0.5-5.5, p=0.460, respectively). Anaemia in FOBT+ subjects was associated with UGI cancers (OR=6.3, 95%CI1.3-31.5, p=0.025) and UGI CSL (OR=4.3, 95%CI2.2-8.4, p=0.0001). Gastrointestinal symptoms were not associated with UGI CSL (OR=1.3, 95%CI 0.6-2.8, p=0.511).

CONCLUSIONS

In FOBT+ subjects there is an appreciable prevalence of UGI cancers and other CSL. Anaemia but not symptoms or colonic pathology are linked to UGI lesions. While the data suggest that same day gastroscopy in FOBT+ subjects undergoing colonoscopy yields approximately 25% more malignancies as colonoscopy alone, prospective data are required to determine the cost-efficacy of dual-endoscopy as a standard of care for all FOBT+ subjects.

Patient characteristics, outcomes and hospital-level healthcare costs of foreign body ingestion from an Australian, non-prison referral centre

OBJECTIVE

Foreign body ingestion (FBI) occurs infrequently but can be associated with rare risks including perforation. There is limited understanding of the impact of adult FBI in Australia. We aim to evaluate patient characteristics, outcomes and hospital costs of FBI.

DESIGN

A retrospective cohort study of patients with FBI was performed at a non-prison referral centre in Melbourne, Australia. International Classification of Disease-10 coding identified patients with gastrointestinal FBI over financial years 2018-2021. Exclusion criteria were food bolus, medication foreign body, object in anus or rectum, or non-ingestion. Criteria for 'emergent' classification were oesophagus, size >6 cm, disc batteries, airway compromise, peritonitis, sepsis and/or suspected viscus perforation.

RESULTS

Thirty-two admissions attributed to 26 patients were included. The median age was 36 years (IQR: 27-56), 58% were male and 35% had a prior psychiatric or autism spectrum disorder. There were no deaths, perforations or surgery. Gastroscopy was performed in 16 admissions and 1 was scheduled following discharge. Rat-tooth forceps were used in 31% and an overtube was used in 3 cases. The median time from presentation to gastroscopy was 673 minutes (IQR: 380-1013). Management was adherent to European Society of Gastrointestinal Endoscopy guidelines in 81%. After excluding admissions with FBI as a secondary diagnosis, median admission cost was $A1989 (IQR: $A643-$A4976) and total admission costs over the 3 years was $A84 448.

CONCLUSION

FBI in an Australian, non-prison referral centre is infrequent, can often be safely managed expectantly, and has limited impact on healthcare utilisation. Early, outpatient endoscopy could be considered for non-urgent cases, which may reduce costs while maintaining safety.

Case report: Joint diagnosis and treatment of intrathoracic gastric duplication with a gastric communication in a child by laparoscopy and gastroscopy

Intrathoracic gastric duplication has rarely been reported. A 5-year-old child with gastric duplication located in the left thorax was diagnosed and treated successfully using laparoscopy combined with gastroscopy. Preoperative computed tomography, upper gastrointestinal contrast study, ultrasound, and other imaging methods were insufficient for accurate diagnosis in this case. Laparoscopy combined with gastroscopy is more suitable for the diagnosis and treatment of gastric duplication.

An unusual complication after endoscopic clipping of a gastric ulcer

A 72-year-old patient presented with malaena secondary to two antral ulcers which were discovered in oesophagogastroduodenoscopy (OGD) after admission. One of the ulcers with a visible vessel was injected with adrenaline and clipped with an OVESCO clip. The patient continued to have coffee ground vomitus on the following day with a drop in haemoglobin level. Repeat OGD showed a large intra-mural haematoma with the clip still in situ and no bleeding from the surface of the ulcer. Patient underwent a coil embolization of the distal gastroduodenal artery (GDA), right gastroepiploic artery and a medial branch of the GDA. Repeat OGD showed that the submucosal haematoma had evacuated, leaving a large, clean-based mucosal defect.

Stem-cell therapy via gastroscopy improves the outcome of esophageal anastomotic leakage

Background

Esophageal anastomotic leakage (EAL) is a severe complication usually occurring after esophagectomy. Although there are various therapeutic methods for EAL treatment, they have not achieved satisfactory results. A previous study showed that the combination of mesenchymal stem cells (MSCs) and fibrin scaffold (FS) can treat EAL. This study aimed to evaluate the efficacy of the injection of MSCs and FS through a new engraftment gastroscope for EAL treatment.

Methods

Twelve adult pigs were randomly divided into the MSCs group (n = 6) and control group (n = 6). A stomach tube was then inserted through the leakage to construct the EAL model, which was removed after one week. The combination of MSCs and FS was autografted at the EAL site for pigs in the MSCs group using the tailor-made gastroscope while only FS was autografted for the pigs in the control group. Local status of EAL was evaluated using gastroscopy. Histological analyses and western blot (WB) were used to assess the gross specimens of esophagi around EALs.

Results

Gastroscopy showed a higher closure rate and a lower infection rate in the MSCs group than in the control group. However, the mortality was not significantly different between the two groups. HE staining showed a severe inflammatory response with dispersive infiltration of inflammatory cells and unhealed leakage in the control group. However, the infiltration of inflammatory cells was not altered in the MSCs group, and the leakage was completely healed. WB analyses showed that Myogenin and α-SMA expressions were significantly higher in the MSCs group than in the control group.

Conclusion

A porcine model of EAL was successfully developed by accessing the transplantation site through the esophagus. Further data revealed that the implantation of MSCs in FS via the novel engraftment gastroscope can promote the repair and occlusion of EAL. Therefore, the proposed method is a promising strategy for EAL treatment.

Effect of Remimazolam Tosilate on Respiratory Depression in Elderly Patients Undergoing Gastroscopy: A Multicentered, Prospective, and Randomized Study

Background

Remimazolam tosilate (RT) is a new type of γ-aminobutyric acid subtype A (GABA_A) receptor agonist, having the possibility to be an ideal sedative drug for procedural sedation. At present, there are few studies on the effect of RT on respiratory depression in elderly patients. We aimed to evaluate the effect of RT on respiratory depression in elderly patients undergoing gastroscopy.

Methods

This prospective, randomized, single-blinded trial recruited patients from eight centers in China between May 2022 and July 2022. A total of 346 elderly patients undergoing gastroscopy were randomly divided into RT group (0.2 mg/kg) or propofol group (1.5 mg/kg), respectively. The primary outcome was the incidence of respiratory depression. Secondary outcomes include the incidence of sedative-related adverse events, the success rate of sedation, time to fully alert, time to loss of consciousness (LOC), time to ready for discharge, as well as the the patients, endoscopists and anethetists' satisfaction.

Results

The incidence of respiratory depression was significantly reduced in the RT group compared with the propofol group (9.8% vs 17.9%, P=0.042). The time of LOC and fully alert in the RT group were longer than that in the propofol group (P < 0.05). The incidences of hypotention (50.9% vs 32.4%, P=0.001) and hypotension requiring treatment (5.8% vs 1.7%, P=0.031) were significantly higher in the propofol group than that in the RT group. The incidence and severity of injection pain were more frequently recorded in the propofol group than that in the RT group (40.5% vs 12.1%, P<0.05). There were no statistically significant differences between the two groups in terms of sedation success rates, time to ready for discharge, endoscopists and anethetists' satisfaction and other sedative-related adverse events.

Conclusion

RT may be a suitable alternative sedative agent for elderly patients undergoing gastroscopy due to its safety profile.

Association of gallbladder diseases with risk of gastrointestinal polyps

BACKGROUND

It has not yet been determined whether gastroscopy and colonoscopy screening help patients with gallbladder diseases. We aim to retrospectively investigate the relationship between gallbladder diseases and gastrointestinal polyps in order to provide a theoretical basis for the early screening of gastrointestinal polyps in patients with gallbladder disease.

METHODS

This is a retrospective cross-sectional study involving 1662 patients who underwent gastroscopy, colonoscopy, and abdominal ultrasound as part of their health check-up from January 2015 to July 2020. We also compared the patients with and without gallbladder diseases to determine the prevalence of gastrointestinal polyps.

RESULTS

Patients with gallbladder polyps had greater odds of having colorectal polyps (adjusted odds ratio (OR)=1.77, 95% confidence interval [Cl]: 1.23 to 2.54, p=0.002) and gastric plus colorectal polyps (adjusted OR=2.94, 95%Cl: 1.62 to 5.32, p<0.001) than those without. Patients with multiple gallbladder polyps had greater odds of having colorectal polyps (adjusted OR=2.33, 95% CI: 1.33 to 4.07, p=0.003) and gastric plus colorectal polyps (adjusted OR=3.95, 95% CI: 1.72 to 9.11, p=0.001), and patients with gallbladder polyps had greater odds of having left-colon polyps (adjusted OR=1.90, 95% CI: 1.25 to 2.88, p=0.003) and colorectal adenoma (adjusted OR=1.78, 95% CI: 1.19 to 2.66, p=0.005). We also noted that women with gallbladder polyps had a higher prevalence of colorectal polyps (OR=2.13, 95% CI: 1.20 to 3.77, p=0.010) and gastric plus colorectal polyps (OR=3.69, 95% CI: 1.58 to 8.62, p=0.003). However, no positive correlation was observed between gallbladder stones and gastrointestinal polyps.

CONCLUSIONS

Gallbladder polyps are significant indicators of colorectal and gastric plus colorectal polyps. Hence, gastroscopy and colonoscopy screening should be performed for patients with gallbladder polyps, particularly female patients and those with multiple gallbladder polyps.

Cost comparison of oral, transnasal and magnet assisted capsule endoscopy in the examination of the upper gastrointestinal tract in patients with dyspepsia

Introduction

Conventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI endoscopic modalities have yet to be performed.

Methods

We performed a cost comparison study of oral, TNE and MACE by a combination of activity-based costing and averaging of fixed costs over 24 481 upper GI endoscopies performed for dyspepsia over a 10-year period.

Results

On average, 9.4 procedures were performed daily. TNE was cheapest at €125.90 per procedure, costing 30% less than oral endoscopy at €184.10 and threefold cheaper than MACE at €407.10. Flexible endoscope reprocessing cost €53.80. TNE was cheaper than oral endoscopy as sedation was not required. Oral endoscopies have a further rate of infectious complications, estimated to cost €16.20 per oral procedure in inpatient admissions. Oral and TNE equipment are more expensive to purchase and maintain than MACE costing €79 330 and €81 819, respectively compared with MACE at €15 420 per annum. However, capsule endoscopes cost significantly more per procedure at €369.00 than the consumables for flexible endoscopy (per oral €12.30, TNE €5.30).

Conclusions

TNE cost less to perform than conventional per oral endoscopy. The cost of capsule endoscopes will need to be reduced significantly if routine use is to be expected.

The median effective concentration of propofol in combination with different doses of esketamine during gastrointestinal endoscopy in adults

We designed a four-arm randomized controlled trial to investigate the median effective concentration (EC50) of propofol in combination with different doses of esketamine inducing appropriate depth of anaesthesia during gastrointestinal endoscopy in adults. One hundred patients aged 18-65 years planning for gastrointestinal endoscopy were divided into four groups randomly: esketamine 0, 0.15, 0.25 and 0.5 mg/kg groups (n = 25). Propofol doses followed the Dixon and Massey up-and-down method with different starting between groups. The primary endpoint was the EC50 of propofol. Secondary outcomes included the cumulative dose of propofol, the duration of the procedure, recovery time, and adverse effects. The EC50 (median, 95% confidence interval) of propofol was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [1.34 (1.15, 1.54) vs. 3.48 (3.25, 3.71), 2.82 (2.58, 3.07), and 2.36 (2.11, 2.61), respectively; p < 0.001]. The total dose of propofol (mean ± SD) required for the whole procedure was significantly less in the esketamine 0.5 mg/kg group compared with the esketamine 0, 0.15, and 0.25 mg/kg groups [95.5 ± 43.1 vs. 277.4 ± 49.0, 207.8 ± 31.6, and 135.1 ± 27.7, respectively; p < 0.001]. The recovery time was significantly longer in esketamine 0 and 0.5 mg/kg group compared with other two groups (p < 0.001). More patients in the esketamine 0.5 mg/kg group experienced visual disturbance compared with the other groups (p = 0.016). Additionally, the incidence of hypotensionin the esketamine 0 mg/kg group after inducation was higher compared with other groups (p < 0.001). In summary, the administration of esketamine significantly and dose-dependently reduced the dose of propofol required to accomplish procedures.

Bridge Swallowing Exercise for Gastroesophageal Reflux Disease Symptoms: A Pilot Study

Objectives

We previously reported that swallowing in the bridge position (bridge swallowing) increased distal esophageal contractions and lower esophageal sphincter pressure against gravity. Moreover, bridge swallowing had the potential to strengthen esophageal peristalsis. In this study, we sought to evaluate whether the bridge swallowing exercise could improve gastroesophageal reflux disease (GERD) symptoms and gastroscopy findings.

Methods

Seventeen subjects with scores of 8 points or higher on the Frequency Scale for Symptoms of GERD (FSSG) questionnaire participated in the study. The exercise of dry swallowing in the bridge posture lasted 4 weeks and was performed ten times per day. FSSG scores were compared before and after exercise. Three of the 17 participants underwent upper gastrointestinal endoscopy. The modified Los Angeles classification of reflux esophagitis was used for objective assessment before and after exercise.

Results

No participants dropped out of this study. FSSG scores improved significantly after exercise (from median [range] 16 [13-21] points before exercise to 5 [4-10] points after exercise, P <0.001). Upper gastrointestinal endoscopy showed improvement in the modified Los Angeles classification grade in one participant.

Conclusions

The bridge swallowing exercise significantly improves FSSG scores. This exercise can be performed easily and safely without adverse events. Further multicenter prospective studies are needed to validate that the bridge swallowing exercise is effective in improving GERD.

Effect of endoscopic resection of gastrointestinal stromal tumors in the stomach under double-channel gastroscopy: A retrospective observational study

We aimed to investigate the safety and efficacy of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors (GISTs) under single-channel gastroscopy and double-channel gastroscopy. We identified 154 patients with GISTs of the stomach who underwent endoscopic resection and were retrospectively analyzed at our hospital between May 2016 and March 2020, including 49 patients by single-channel gastroscopy and 105 patients by double-channel gastroscopy. We observed the clinical efficacy, complications, and safety of endoscopic resection of gastric GISTs, and the data were evaluated retrospectively. All patients underwent endoscopic resection successfully, without conversion to open surgery. In the single-channel gastroscopy group, 7 patients had lesions in the gastric cardia, 17 in the gastric fundus, 20 in the gastric corpus, and 5 in the gastric antrum. In the double-channel gastroscopy group, 13 patients had lesions in the gastric cardia, 34 in the gastric fundus, 46 in the gastric body, 10 in the gastric antrum, 1 in the pylorus, and 1 in the gastric angular incisure. The double-channel gastroscopy group had a shorter operation time than the single-channel gastroscopy group (59.9 ± 34.9 minutes vs 74.8 ± 26.7 minutes; P = .009 and P < .01, respectively), while they also had a lower perforation rate than the single-channel gastroscopy group (34.3% vs 51.0%; P = .048 and P < .05, respectively). No residual or recurrent lesions were discovered in any patients by gastroscopy reexamination. Both single-channel gastroscopy and double-channel gastroscopy can provide safe, effective, feasible endoscopic resection. However, double-channel gastroscopy has some distinct advantages in endoscopic resection.

Endoscopy Training in Small Animal Internal Medicine: A Survey of Residency Training Programs in North America

Competency in multiple endoscopic techniques is a major goal of small animal internal medicine (SAIM) residency programs. Training relies predominantly on mentored supervision of procedures performed on patients. Supplementation of this apprenticeship model with classroom sessions and hands-on laboratories can be advantageous to trainees and patients. Few veterinary resources describe supplemental training options, and no single source exists for mentors to consult for program development. The purpose of this study was to describe the supplemental training opportunities currently available to SAIM residents at academic hospitals in the US and Canada and to compare their timing during the residency, resident and faculty time commitment, and perceived helpfulness. Data were collected by an electronic survey distributed to one faculty member per institution. The response rate was 80% (24/30). Most programs (22/24; 92%) offered some form of supplemental training, including classroom sessions (9/24) and hands-on laboratories using physical models (7/24), virtual reality simulators (2/24), and cadaver (2/24) and anesthetized (2/24) dogs. Fifteen programs provided residents with the opportunity to attend external endoscopy workshops. Only three programs required any training prior to residents performing procedures on patients. There was considerable variability in training between programs, precluding statistical comparisons. The survey identified topics for classroom sessions and several inexpensive physical models, rated very or extremely helpful, that would be suitable for programs with limited budgets. A human-based virtual reality simulator was also rated highly by two programs. Comprehensive, external workshops evoked numerous positive comments with perceived value ranging from somewhat to extremely helpful.

Percutaneous endoscopic gastrostomy using the introducer method with ultra-slim endoscopy in amyotrophic lateral sclerosis patients with respiratory compromise: A safe technique

BACKGROUND AND AIM

Percutaneous endoscopic gastrostomy (PEG) placement is recommended in patients with amyotrophic lateral sclerosis (ALS), but the procedure is considered high risk. In this study, we aimed to compare the outcome of ALS patients with and without PEG. The success of the procedure and complications of PEG insertion were also explored.

METHODS

Patients with ALS who met the criteria for enteral feeding support were consecutively recruited. Patients who consented had PEG insertion using the modified technique of introducer method with transoral ultra-slim endoscopy.

RESULTS

A total of 64 patients were recruited, of which 36 (56%) patients consented to PEG. The median age of all patients was 65 years and 59% were male. There was no difference in demographic and clinical characteristics between patients who agreed to a PEG and those who did not. The mortality rate at 6 and 12 months was lower in the PEG cohort compared with non-PEG, but this was not statistically significant (6 months: 28.6% vs 32.2%, P = 0.561; 12 months: 38.9% vs 50.0%, P = 0.374). Amongst the PEG cohort, 61% were stratified high risk and 31% moderate risk. Thirty-one percent of them required long-term home noninvasive ventilation. All patients (100%) underwent successful PEG insertion at single attempt using the modified approach. The complications reported over a period of 6 months were infected PEG site (17%), dislodged gastrostomy tube (14%), and minor bleeding (8%).

CONCLUSION

In ALS patients with moderate to high risk of PEG insertion, the introducer technique utilizing ultra-slim endoscopy guidance was well tolerated and safe.