DAY CARE MEDICINE SURGERY
Outpatient Therapeutic Gastrointestinal Endoscopy : Scope and Limitations
We live in an era of minimally invasive therapy. Therapeutic gastrointestinal endoscopy has been at the forefront as a minimally invasive treatment modality for a variety of digestive diseases. Furthermore, a large number of therapeutic endoscopic procedures are being evaluated as outpatient treatment modalities. With spiralling health care costs, outpatient minimally invasive treatment modalities seem to be very cost-effective. However we must lay down guidelines and have benchmarks as to which endoscopic procedures can be safely performed on an outpatient basis. This is important from the medico-legal point of view as well. In this overview I have tried to rationalise the practise guidelines for doing various therapeutic gastrointestinal endoscopic procedures on an outpatient basis.
The two key issues, which govern performing outpatient endoscopy, are patient related risk factors and stratification of endoscopic procedures into low risk (basic) and high risk (advanced) procedures.
Stratifying Patient Risk Factors
If the patient has any of the risk factors as in Table 1, he should clearly not undergo any endoscopic procedure on an outpatient basis. The merits of doing a diagnostic endoscopic procedure of course can be considered on an individual basis.
Stratifying Endoscopic Procedures
High Risk Patients for Endoscopy
-Coronary artery disease.
-History of myocardial
-Congestive heart failure.
-Interstitial lung disease.
-History of stroke.
-Elderly or young age.
-Chronic use of prescribed
History of drug allergy.
History of radiation
Endoscopic procedures can be broadly classified into diagnostic and therapeutic. Therapeutic procedures can be further sub-classified as basic (could be done as out-patient procedures) and advanced (requiring hospital admission). There is no doubt that in an otherwise fit patient most of the diagnostic endoscopic procedures (Table 2) can be performed on an outpatient basis. The main issue is the utilisation of outpatient facility for performing various therapeutic endoscopic procedures. Even if therapeutic endoscopic procedures are being done on an outpatient basis, the patient should be within a 10 minute driving distance from a medical facility and be contactable over the telephone. It needs to be emphasised that high-risk therapeutic endoscopic procedures are performed in hospitals for monitoring and early detection of complications as discussed below.
Diagnostic Endoscopic Procedures
Active upper or lower gastrointestinal bleeding
Clearly, patients with active upper or lower gastrointestinal bleeding need to be immediately admitted to a hospital, and if necessary into an intensive care unit or GI bleeding unit. Ambulatory, outpatient or office-based endoscopic procedures should never be done in these patients.
Interval treatment for gastrointestinal bleeding
Children undergoing interval treatment for oesophageal varices must be admitted in the hospital. Similarly patients undergoing glue injection for fundic varices (not bleeding) should not be treated in ambulatory endoscopy units since torrential bleeding can occur during therapy.
Dilatation of complex oesophageal strictures
Dilatation of long, tortuous oesophageal strictures, either benign or malignant carries a definite risk of oesophageal perforation and hence patients need to be admitted. Patients with malignant oesophageal strictures associated with tracheo-oesophageal fistulas should also be admitted in the hospital for dilatation since respiratory complications may occur.
Oesophageal self-expanding metal stent (SEMS) placement
In experienced centres, oesophageal SEMS placement has become very safe. However, patients with associated tracheo-oesophageal / oesophago-bronchial fistulas as mentioned need in-hospital admission. Also, patients with high oesophageal stricture (cervical oesophagus) need to be admitted to look for respiratory embarrassment after SEMS placement including strider.
Percuatneous endoscopic gastrostomy (PEG)
Although PEG is a relatively safe procedure, patients need to be admitted for pre and post procedure antibiotics. Also, following the procedure, the patient is kept without enteral feeds for 8-24 hours and needs to be administered intravenous fluids. Needless to say early complications may be detected if the patient is in the hospital post-procedure.
Hospital Based Therapeutic Endoscopic Procedures
1. Therapeutic Upper GI Endoscopy
-Active upper or lower gastrointestinal bleeding.
-Glue injection for fundic varices (active or interval).
-Interval treatment for oesophageal varices in children.
-Dilatation of complex oesophageal strictures.
-Oesophageal SEMS placement (complex, associated TOF, cervical).
-Percutaneous endoscopic gastrostomy.
-Balloon dilatation of high-grade, complex benign duodenal stenosis.
-Endoscopic mucosal resection.
2. Therapeutic Lower GI Endoscopy
-Colonoscopic polypectomy (multiple, large, piecemeal).
-Colonic tube placement.
3. Biliary-Pancreatic Endoscopy
-Biliary sphincterotomy in small papilla.
-Naso-biliary tube placement.
-Mechanical lithotripsy, electrohydraulic or laser lithotripsy for large CBD stones.
-Biliary hilar stricture.
-Double duct stenting.
-First sitting endoscopic treatment of chronic
pancreatitis (pancreatic sphincterotomy, stone
extraction, stricture dilatation, stenting).
-Endoscopic pseudocyst drainage.
-Rendevouz technique for ERCP.
-ERCP in operated stomach.
Endoscopic mucosal resection
With this procedure torrential bleeding and at times perforation can occur and hence in-hospital admission is recommended.
Although colonoscopic polypectomy is a relatively safe procedure, patients who have large polyps have a definite risk of early bleeding and hence hospitalisation needs to be done. Similarly, if piecemeal polypectomy is done for large sessile polyps, there is an increased risk of perforation.
Colonic tube placements
Colonic tube placement or cecostomy for pseudo-obstruction obviously will be performed only in hospitalised patients.
Therapeutic biliary endoscopy
The most controversial issue is performing therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) on an outpatient basis. Patients with either a small papilla or in whom a needle-knife sphincterotomy is done need to be hospitalised due to the increased risk of complications particularly pancreatitis. Patients who require naso-biliary tube placement for cholangitis also need to be hospitalised to monitor the drainage, give biliary toilet and for parenteral antibiotics. If one is performing endoscopic treatment for large common bile duct (CBD) calculi such as mechanical lithotripsy, electro-hydraulic or laser lithotripsy need to be hospitalised to look for complications of sphincterotomy and cholangitis. As for biliary strictures, patients undergoing treatment for placement of stents (plastic or SEMS) in the proximal bile duct should be admitted due to the higher incidence of cholangitis. Similarly patients who are undergoing double biliary duct stenting for hilar strictures need to be hospitalised for the same reason. Patients undergoing ERCP for post-cholecystectomy complications such as biliary leak or obstructive jaundice should also be hospitalised.
Therapeutic pancreatic endoscopy
Patients who are undergoing their first session of pancreatic stricture dilatation, stone removal or pancreatic stenting or those in whom a pancreatic sphincterotomy is performed should be admitted since they may experience severe pain after the procedure requiring parenteral analgesia. Patients who are undergoing endoscopic treatment of pancreatic pseudocyst need hospitalisation as well.
Complex biliary-pancreatic endoscopy
In certain complex situations such as performing ERCP in an operated stomach or in patients undergoing combined percutaneous and endoscopic procedures (rendezvous ERCP) hospitalisation is recommended. Also patients undergoing specialised procedures such as ampullectomy or percutaneous cholangioscopy need to be hospitalised.
Interval endoscopy for gastrointestinal bleeding
Patients who come for interval treatment for oesophageal variceal band ligation or oesophageal variceal sclerotherapy may be done in an ambulatory or outpatient facility especially if the varices or not too large and the liver disease is not advanced. Patients requiring treatment with argon plasma coagulation for conditions such as colonic arterio-venous malformations, solitary rectal ulcer or radiation proctitis can be safely treated on an outpatient basis provided they are not actively bleeding.
Dilatation of benign strictures
Benign strictures in the oesophagus, duodenum or colon can be dilated using bougies or balloons on an outpatient basis provided that the strictures are not complex (high-grade, long, tortuous).
Treatment of achalasia cardia
Pneumatic dilatation of achalasia cardia or botulinum toxin injection can both be performed on an outpatient basis and patients kept for 4-6 hours post-procedure for observation.
Placement of oesophageal SEMS
Patients who have oesophageal tumours either in the mid-oesophagus or at the cardia and without a tracheo-oesophageal fistula can undergo oesophageal SEMS placement on an outpatient basis. Re-interventions for complications following SEMS can usually be performed on an outpatient basis including re-stenting if necessary.
Patients who need to convert the percutaneous gastrostomy to a jejunostomy can have the procedure done on an outpatient basis.
Endoscopic treatment for gastro-oesophageal reflux disease (GORD)
At present endoscopic treatment for GORD includes either endoscopic suturing (Endocinch) or use of radiofrequency ablation of the lower oesophageal sphincter (Stretta device). Both of these procedures can safely be done on an outpatient basis.
Therapeutic biliary-pancreatic endoscopy
Patients who have undergone uncomplicated over-the-wire sphincterotomy or a simple extraction of a common bile duct calculus need not be hospitalised after the procedure. Patients who have a distal bile duct stricture for which a biliary stent insertion (plastic or SEMS) is being done can be discharged after recovery. Similarly, biliary or pancreatic stent exchange can be done on an outpatient basis.
Endoscopic ultrasonography (EUS) guided fine needle aspiration cytology (FNAC)
Diagnostic EUS, intraductal EUS and EUS guided FNAC procedures for obtaining tissue diagnosis from mediastinal tumours, pancreatic masses can be performed on an outpatient basis.
The field of therapeutic endoscopy has made treatment of many digestive disorders safe, efficacious and cost-effective. We are moving ahead and are today aiming to perform procedures entirely on an outpatient basis. This seems to be a very attractive approach for treating patients with various digestive disorders. However we must temper our enthusiasm with wisdom and knowledge. The approach mentioned in this article is at the most tentative and should not be perceived as authoritative recommendation. Only prospective trials will reveal whether the above can be incorporated as standard of care in endoscopy practise. Till then we must treat each case on an individual basis.