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Background: Percutaneous endscopic gastrostomy (PEG) placement is standard in the care of patients with amyotrophic lateral sclerosis (ALS) unable to maintain adequate oral nutrition. This has been performed using conscious sedation with narcotics/benzodiazepines. However, recent studies suggest that propofol sedation is superior for other endoscopic procedures. In addition, endoscopic PEG placement is not recommended for patients with ALS with a forced vital capacity (FVC) <50%. The authors postulated that nurse-administered propofol sedation (NAPS) with the addition of bilevel positive airway pressure (BiPAP) would be superior to standard sedation with midazolam/fentanyl (M/F) in all patients with ALS regardless of FVC. Here the authors review their retrospective experience of PEG placements in patients with ALS using propofol ± BiPAP vs traditional sedation ± BiPAP., Results: Thirty-one patients received M/F, and 29 received NAPS. BiPAP was used more often in the NAPS group (24/29 NAPS vs 6/31 M/F respectively, P < .0001). Twenty-nine of 31 PEG placements in the M/F group and 27 of 29 PEG placements in the NAPS group were successful. Seven desaturation events occurred to <90% in the M/F group compared with 1 desaturation event in the NAPS group (P = .05). No other complications were noted., Conclusion: PEG placement can be performed safely in patients with ALS with FVC <50% using NAPS with BiPAP.

Background: The overwhelming majority of reported duodenal and colonic SEMS placements in the literature have used the 0.035″ guidewire almost to the exclusion of guidewires of other diameters., Aims: The purpose of this study was to compare technical and clinical outcomes in patients undergoing duodenal or colonic SEMS placement with 0.025″ or 0.035″ guidewires., Methods: This was a retrospective study to compare technical and clinical outcomes and complications of patients receiving duodenal or colonic SEMS placement with a 0.035″ guidewire to those undergoing placement with a 0.025″ guidewire., Results: A total of 34 duodenal and 30 colonic stent placement procedures were performed in 59 patients. Technical success was achieved in all duodenal stent placement procedures. The difference in mean GOOSS score increase after stent placement was not statistically significant between the 0.035″ and 0.025″ guidewire groups (P = 0.49). Complications were not statistically significantly different between the two groups undergoing gastroduodenal stenting. Technical and clinical success was achieved in all colonic stent placement procedures. There were no statistically significant differences in complication rates between the two groups undergoing colonic stenting. Procedure times were not significantly different using either wire type., Conclusions: Our study shows that both 0.035″ and 0.025″ guidewires were equally effective with regards to technical success, clinical success, and with regards to the development of complications.

Purpose of Review: Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present., Recent Findings: Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement., Summary: Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.

Background: Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement., Methods: This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1-mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time., Results: Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00). The endoscopic procedure duration (12.8 +/- 6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 +/- 12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 +/- 6.2 minutes to 8.0 minutes +/- 4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures., Conclusions: NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.

Background: Gastric intestinal metaplasia (GIM) is a premalignant gastric mucosal change that is often incidentally detected during esophagogastroduodenoscopy (EGD). Despite the established higher risk of gastric cancer associated with GIM, the incidence, prevalence, and outcomes data for GIM are limited in the United States (US), and practice patterns are highly variable. Objectives: Our primary objectives were to accurately identify incident histology-confirmed GIM cases and determine patient characteristics, endoscopy findings, Helicobacter pylori (HP) detection, and eradication treatment outcomes, as well as surveillance and follow-up recommendations. Design: We conducted a retrospective cohort study using administrative data. Methods: We first developed and validated a rule-based natural language processing tool to identify the patients with GIM on gastrointestinal pathology reports between 2011 and 2016. We then performed a manual chart review of all EGD procedures and associated pathology notes to confirm cases and obtain clinically relevant data. Results: In all, 414 patients with an index diagnosis of GIM were confirmed (prevalence = 2.5% of patients undergoing any EGD). A majority (52.4%) of patients were non-Hispanic white. The most common indication for EGD was abdominal pain (46.9%). A majority (55%) did not receive specific follow-up recommendations or were asked to see their primary care provider. HP testing was documented in 86% of patients, and detected in 94 patients (prevalence = 26.4%). Treatment was documented in 94.7% of cases, and eradication confirmed in only 34.8% of these cases. Conclusion: A large group of US patients with an index diagnosis of GIM was accurately identified. There was wide variability in clinical practice patterns including biopsy practice, HP treatment and eradication confirmation testing, and surveillance recommendations. This work demonstrates that there is a major unmet need for quality improvement efforts to standardize care for patients with GIM, a premalignant condition, and inform future prospective studies in a US population. [ABSTRACT FROM AUTHOR]

Background: Endoscopic intrapyloric Botox (onabotulinumtoxin A; Allergan Pharmaceuticals) injections can improve postfundoplication gastroparesis, but responses are not durable. Surgical pyloroplasty may relieve gastroparetic symptoms, but patient selection criteria are poorly defined. We hypothesize that pyloroplasty provides durable improvement in patients whose symptoms improved after Botox injection.Study Design: A retrospective chart review was performed of patients with postfundoplication gastroparesis who improved after Botox injection and then underwent pyloroplasty. Gastric emptying studies (GES), Gastroparesis Cardinal Symptom Index (GCSI) score, symptoms, and outcomes were reviewed.Results: Ten patients received Heineke-Mikulicz pyloroplasty after reporting improvement with Botox injection. The mean operative time was 114 minutes (range 55-234 minutes). Three of 10 patients required conversion to open surgery, and the median length of stay was 3 days. Gastroparesis symptom improvement occurred in 9 of 10 patients. Postoperative GES normalized in 5/5 patients (median 205 decreased to 70 min, P < .05). Median preoperative GCSI was 3.67, improved to 2.22 at 1 month postsurgery (P = .010) and to 2.11 on most recent follow-up (P = .015). Median duration of follow-up was 34 months (range 1-101 months).Conclusion: Heineke-Mikulicz pyloroplasty can improve symptoms and gastric emptying times in patients with postfundoplication gastroparesis. Improvement with intrapyloric Botox injection may select candidates for pyloroplasty. [ABSTRACT FROM AUTHOR]

We report a case series of 4 patients who underwent routine gastrointestinal endoscopy under moderate sedation and developed corneal injuries. Although corneal abrasion has been reported as the most common ocular complication during non-ocular surgery under general anesthesia, the risk for corneal abrasion during routine endoscopic procedures using moderate sedation has not been previously reported. Symptoms reported included ocular burning, scratchy sensation, redness, and pain reported post-procedure. Endoscopists and staff should be alert to the occurrence of this potentially serious complication, as this is paramount for its prevention, diagnosis, and management. Treatment of corneal abrasion includes referral to ophthalmology for close monitoring, pain management, pressure patch, and antimicrobial prophylaxis. [ABSTRACT FROM AUTHOR]

OBJECTIVES:We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career.METHODS:A survey was e-mailed to all US GI fellowship program directors and distributed at fellows’ endoscopy courses. Data were evaluated via univariate and multivariate analysis.RESULTS:One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age >35 years, prior attainment of a master’s or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors.CONCLUSIONS:Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine. [ABSTRACT FROM AUTHOR]