Management of complications

In this anniversary editorial celebrating 50 years of Endoscopy, we focus on complications in endoscopy. In a paper from Denmark in 1978, Andersen and Clausen reported a study encompassing three important endoscopy topics: complications associated with endoscopy and the related themes of sedation and the outpatient setting [1].

We noticed first that the authors only focused on stomach-related indications and pathologies (e. g. 23 % gastritis, 17 % gastric ulcer), and did not report any symptoms or diseases from the esophagus or the duodenum. At the time, the role of endoscopy was primarily gastric exploration, and it was only later that esophageal pathology was included as a major indication for endoscopy. This paper is also interesting in revealing that gastric exploration was conducted routinely with side-viewing endoscopes and that all gastroscopies were preceded by a barium meal examination, which nowadays is limited to very rare cases of dysmotility.

Andersen and Clausen gathered data on the full range of complications, including tooth damage, which accounted for three of the seven reported complications in their study of 625 patients undergoing outpatient gastroscopy. Tooth damage is recorded by endoscopy units but is not usually reported in publications. Tooth damage is also observed during tracheal intubation performed for general anesthesia. The complication rate is quite low in this article and is mainly related to the patient’s condition (pre-perforative ulcer and heart rhythm disorders). In addition to the numerical data collected by the authors, it is interesting that they extended their study to cover complications after endoscopy as well, issuing questionnaires to the 101 referring physicians in order to gather information on complaints reported by patients following endoscopy. In 1978, it was certainly novel to take into account delayed complications. However, this study did not focus on a precise delay and did not report the complications that occurred within 30 days of the procedure.

Over the past 50 years, the topic of complications in digestive endoscopy has undergone four major evolutions. The first evolution has been an increase in the frequency of complications, owing to the development of interventional endoscopy. In particular, complications related to endoscopic retrograde cholangiopancreatography have been found to be relatively frequent, severe, and sometimes fatal. More recently, morbidity is one of the major reasons for the slow emergence of endoscopic submucosal dissection in Western countries.

The second major change has been improvement in the quality of data collection regarding complications, including quantification of the severity of complications. In a recently published statement [2], the European Society of Gastrointestinal Endoscopy (ESGE) recommends applying the same principles as those adopted by the airline industry and to have in place “…a process for capturing and reviewing adverse events to determine whether further improvements are required.” All safety-related events, both expected and unexpected, should be identified. Another recent paper [3] suggests that the capture of side-effects can be incomplete even in clinical quality registers.

It has also become possible to endoscopically treat complications during the same endoscopy session, whereas prior to these technical advancements the corrective treatment was almost exclusively surgical. The first such remedial endoscopic approach was hemostatic modalities to treat digestive hemorrhage induced by endoscopy. Mönkemüller and Soehendra recently commented that although key mechanisms of hemostasis such as injection, mechanical, thermal, and topical methods, are quite well established, there are various promising techniques that are still evolving, such as sprays and over-the-scope clips [4]. More recently, endoscopists have been able to treat iatrogenic perforation thanks in particular to clipping technology.

Above all, endoscopists should know that the treatment of complications requires an individualized approach and dedicated training in all techniques. An interesting semantic question is to decide whether complications such as bleeding and perforation are still considered as complications if they can be treated adequately during the procedure. Of course, delayed events are still complications and, for example, perforations cannot always be resolved by closure of the defect but may also require associated drainage, including vacuum therapy.

In a position statement on the diagnosis and management of iatrogenic endoscopic perforations [5], ESGE recommends that “…each center implements a written policy regarding the management of iatrogenic perforation. This policy should be shared with the radiologists and surgeons at each center. In the case of an endoscopically identified perforation, ESGE recommends that the endoscopist reports: its size and location with a picture; endoscopic treatment that might have been possible; whether carbon dioxide or air was used for insufflation.”

The final major change regarding complications in endoscopy has been the prevention of complications by following the recommendations of scientific societies such as ESGE. ESGE aims to cover the entire field of digestive endoscopy, with over 50 guidelines published and updates issued at least every 5 years. In particular, the guidelines encompass important safety issues, such as antibiotic prophylaxis, anticoagulation management, and endoscope reprocessing [6]. ESGE has also defined quality parameters and is establishing curricula to guide practice and to reduce complication rates.

Regarding the modalities of endoscopy practice, the outpatient examination, which was the setting for the Danish paper, remains more relevant than ever for several reasons, such as consumer expectation and cost containment.

And finally, the 1978 Endoscopy paper reports the use of intravenous diazepam for sedation. Nowadays, sedation is widely used in digestive endoscopy and the best single sedation agent for endoscopy is propofol. Propofol has maintained the quality of traditional sedation, but because of its pharmacodynamic profile, it permits shorter induction and recovery times and higher patient satisfaction. ESGE guidelines also provide the framework for endoscopists to perform nonanesthesiologist administration of propofol in their countries.

The last 50 years have seen us progress from the realization that complications can occur during endoscopy to a modern management practice for these complications, thanks to an armamentarium of new techniques and guidelines from scientific societies. Furthermore, outpatient practice is ever more critical to meet the demands of endoscopy services, fuelled in part by the expansion of interventional endoscopy, effective management of complications, and improvement in sedation modalities.

Fig. 1 Perforations and leaks of the gastrointestinal (GI) tract. Perforations, leaks, and fistulae of the GI tract may occur as a result of surgery, ingestion of foreign bodies, retching, trauma, inflammatory and neoplastic conditions, and as a complication from diagnostic and interventional endoscopy. The graphic shows common areas of luminal GI damage such as esophageal perforation, dehiscence of anastomosis after surgery, duodenal perforation during endoscopic retrograde cholangiopancreatography or endoscopic ultrasound, and colonic leaks and perforations. The therapeutic endoscopist should be able to manage most of these discontinuities of the luminal GI tract with various devices such as those as shown on figures b to f: fully covered self-expandable metal stent, through-the-scope clips, over-the-scope clip, and endosponge. Of course, the armamentarium of the therapeutic endoscopist should also include overtubes, glues, injection needles, and endoloops. Illustration: Kirsten Tucker. Legend and photos: Klaus Mönkemüller.

• References

• 1 Andersen KE, Clausen N. Out-patient gastroscopy risks. Endoscopy 1978; 10: 180-183
• 2 Valori R, Cortas G, de Lange T. et al. Performance measures for endoscopy services: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1-19
• 3 Hoff G, de Lange T, Bretthauer M. Registration bias in a clinical quality register. Endosc Int Open 2019; 7: E90-E98
• 4 Mönkemüller K, Soehendra N. Endoscopic treatments for gastrointestinal bleeding: a story of cleverness and success. Endoscopy 2019; 51: 5-6
• 5 Paspatis GA, Dumonceau JM, Barthet M. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2014; 46: 693-711
• 6 Beilenhoff U, Biering H, Blum R. et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Update 2018. Endoscopy 2018; 50: 1205-1234