Background: The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients while advocating for using noninvasive studies for intermediate and low risk individuals. Both guidelines recommend direct endoscopic retrograde cholangiopancreatography (ERCP) for ascending cholangitis and choledocholithiasis on imaging. As per 2010 guidelines, total bilirubin > 4 mg/dl and total bilirubin between 1.8 to 4 mg/dl along with dilated bile duct on imaging met criteria for direct ERCP. In 2019 guideline, this was changed to total bilirubin > 4 mg/dl in combination with CBD dilation > 6 mm as an indication for direct ERCP. We aim to compare the performance and diagnostic accuracy of 2019 vs 2010 criteria for predicting choledocholithiasis. Methods: From a prospectively maintained database (2013 to 2019) of over 10,000 ERCPs performed by 70 Gastroenterologist's in our hospital system comprising of 14 hospitals, a random sample of 1400 ERCPs with indication of choledocholithiasis was selected. Data regarding demographics, total bilirubin level, imaging studies such as abdominal ultrasound, computed tomography of abdomen or magnetic resonance cholangiopancreatography (MRCP), Intraoperative cholangiogram (IOC), Endoscopic ultrasound (EUS) and ERCP results were retrospectively collected by chart review. Patients with prior sphincterotomy were excluded. Results: From a random sample of 1400 ERCPs, 843 patients had native papilla and were included in the study. Both 2010 and 2019 guidelines were applied to the same patient population. Overall, 61.2% (518) were deemed high risk and met criteria for direct ERCP as per 2010 guidelines compared to only 37.7% (318) as per revised 2019 guidelines. This difference of 200 patients (24%) was statistically significant as per z statistics comparing two population proportions (p value < 0.001). Choledocholithiasis were found at ERCP in 76.5% (395/518) as per 2010 guidelines, compared to 82.1% (261/318) of those who met the 2019 high risk criteria. Once again, this difference (76.5% vs 82.07%, respectively) was statistically significant (p value < 0.001). In our patient cohort, overall specificity of 2010 guidelines was 46.9% and this improved to 75.0% as per 2019 criteria (Table 1). Conclusion: Our study shows that the strategy proposed by updated 2019 ASGE guidelines is more specific for detection of choledocholithiasis when compared to the 2010 criteria. These findings suggest adherence to the new guidelines would potentially minimizes the procedure adverse events for those individuals who do not meet the high-risk criteria.
Soft tissue sarcomas represent an extremely rare cause of esophageal masses, and undifferentiated sarcomas are rarer. The proportion of dedifferentiated liposarcomas (DDL) is even lower. The case of a 58-year-old male who complained of dysphagia and was found to have an 18-centimeter long esophageal mass/polyp on esophagogastroduodenoscopy is presented. The lesion was resected endoscopically and a diagnosis of DDL was confirmed by fluorescence in situ hybridization. Due to its rarity, the treatment experience with esophageal DDLs is limited. However, based on our experience, endoscopic resection of the lesion can be considered as the treatment of choice when feasible. We performed a review of the literature to identify and analyze similar reported cases.
Introduction: Millions of screening colonoscopies are performed annually which means there is a substantial health cost for insurances. There has been more utilization of deep sedation requiring costly anesthesia services compared to moderate sedation given severity of systemic diseases, increased comfort, satisfaction, and ease of scoping for the endoscopist. Typically, obese patients with obstructive sleep apnea (OSA) have required deep sedation, however many are able to utilize moderate more safely. Here we assess respiratory complications in deep and moderate sedation in high risk patients who have obesity and OSA undergoing a screening colonoscopy. Methods: A retrospective cohort study was done in patients with obesity and OSA who have undergone a screening colonoscopy between 2014 and 2018 with either moderate or deep sedation. Background history included age, sex, race, BMI, alcohol, tobacco and marijuana use. Complexity and airway was measured by ASA and Mallampati score (MS). OSA severity was assessed by the AHI score. Moderate sedation was supervised by the endoscopist using midazolam with fentanyl or meperidine. Deep sedation was done with anesthesia staff using propofol. Intra-procedure respiratory complications were assessed by apneic episodes as determined by the end tidal CO2. Results: 458 patients with OSA and obesity, with 49.1% undergoing moderate sedation, were analyzed. There were no major background differences in sex, age or BMI (table 1). A significant race difference was noted between the two groups with majority African American (59.6%) for deep and Caucasian (59.1%) for moderate sedation (p<.001, table 1). Overall, the mean diagnostic AHI was 48.0 and recent AHI 5.3. The majority ASA class in moderate sedation was ASA II compared to ASA III in deep sedation (p<.001, table 1). MS II was most prevalent in both sedation groups with more MS III in deep sedation compared to moderate sedation (p<.001, table 1). Intra-procedural respiratory depression was significantly noted in deep sedation (5.2% vs 0.9%, pZ0.008). Interventions solely for deep sedation included 1 oral airway insertion and 3.4% needing intubation (pZ0.007, table 2). Discussion: There is a notable increased respiratory risk in deep sedation. Patient's requiring intra-procedural intubation can go on to have further post-procedure complications. Traditionally, ASA III and MS III are done with anesthesia, however this study showed that patients with similar ASA and MS were able to undergo moderate sedation with little to no complications. These findings go on to advocate that while close airway monitoring with anesthesia is common in obese patients with OSA, moderate sedation carries much less risk and should be the preferred modality. It is also certainly more cost effective without the need for anesthesia services cutting down a sizeable amount of healthcare costs.
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