Falling Down the Rabbit Hole of Irrational Endoscopy Requests
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PERSPECTIVE
Falling Down the Rabbit Hole of Irrational Endoscopy Requests Amnon Sonnenberg1,2 Received: 23 September 2020 / Accepted: 6 October 2020 © This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020
After a failed sleeve gastrectomy, a 38-year-old man underwent subtotal gastrectomy and Roux-en-y anastomosis [1]. Five days after the operation, the patient developed abdominal pain and was unable to swallow any food or liquids. The abdominal CT scan revealed no obvious esophageal obstruction, but a small gastric pouch appeared filled with food. The gastroenterology service was requested to do an emergency esophago-gastro-duodenoscopy (EGD) for disimpaction of the gastric pouch. The gastroenterology service pointed out that disimpaction of a gastric pouch would constitute an unusual therapy outside the standard repertoire of endoscopic procedures dealing with gastroparesis or complications following gastric surgery [2, 3]. In general, unusual indications are associated with an increased risk for adverse outcomes, especially in light of the patient’s recent surgery [4, 5]. The surgical team insisted on the EGD as the only available option other than surgical revision and scheduled an EGD in the operating room under general anesthesia. After speaking to the patient and examining him, the gastroenterologist felt that the patient’s symptoms had resolved and that a diagnostic EGD under deep sedation might suffice to resolve the issue. If need be, one could still insert an overtube for disimpaction and airway protection [6]. However, the anesthesiologist raised concerns about patient safety and pressed for tracheal intubation with general anesthesia. Eventually, an EGD took less than 10 min to complete. It revealed normal gastrointestinal anatomy after subtotal gastrectomy with a patent gastro-jejunal anastomosis. The gastric pouch contained few remnants of food that were suctioned out to reveal unremarkable gastric mucosa underneath. The example from above serves to illustrate similar types of unusual endoscopy requests by patients themselves or their
* Amnon Sonnenberg [email protected] 1
The Portland VA Medical Center, P3‑GI, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA
Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR, USA
2
healthcare providers. Such requests include, for instance, colonic decompression; access to remote extraintestinal lesion in the thorax or abdomen; closure of fistulas between the enteric and pulmonary, vascular, or urogenital system; hemostasis in instances of massive bleeding and bleeding from obscure or incurable lesions. Such requests reflect on underlying misconceptions about gastrointestinal endoscopy and its function, applicability, limitations, and risks. Gastroenterology frequently acts as ancillary service, responding to consult requests by other medical subspecialties. Trying to oblige and be supportive, the endoscopist sometimes finds it diffic
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