Same-day performance of esophagogastroduodenoscopy (EGD) and colonoscopy is called bidirectional endoscopy (BDE). BDE is commonly performed, but the optimal sequence for which procedure to do first is not well established. This is the first study in the US to investigate the optimal sequence for BDE.

We performed a cohort study of patients with same-day BDE (2003-2018) at our institution. The two study groups were (1) EGD followed by colonoscopy (UL) and (2) Colonoscopy followed by EGD (LU). Endpoints included procedure duration, extent reached, sedation, and diagnostic yield.

22,905 patients underwent BDE, with complete data available for 16,538. 14,325 underwent UL, and 2213 underwent LU. For diagnostic indications, the LU group was more likely to require opiates (OR 2.8, CI 2.5-3.3, p < 0.001), benzodiazepines (OR 3.0, CI 2.6-3.4, p < 0.001), antihistamines (OR 1.5, CI 1.2-1.8, p < 0.001), while less likely to require anesthesia (OR 0.33, CI 0.28-0.39, p < 0.001). Similar results were found for surveillance indication of endoscopy and in screening colonoscopy, with no differences in EGD screening indications. Total Procedure duration: UL had shorter total procedure duration (23.2 vs. 28.8 min; p < 0.001), EGD duration (5.4 vs. 6.5 min; p < 0.001), and colonoscopy duration (17.9 vs. 22.3 min; p < 0.001). Diagnostic yield: UL and LU sequences had comparable polyp detection rates (37.6% vs. 38.1%, p = 0.65) with similar adenoma detection rates (ADR).

Performing EGD first resulted in shorter procedure times and a reduced likelihood of requiring opioids and benzodiazepines, with no differences regarding procedure-related adverse events or diagnostic yield.

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Background: Previous studies have favored esophagogastroduodenoscopy (EGD) followed by colonoscopy as the optimal sequence in bidirectional endoscopy (BDE) with air insufflation. However, the optimal sequence in same-day BDE with WE colonoscopy is unclear. Methods: A total of 200 patients undergoing BDE with propofol sedation from May 2018 to January 2021 were randomized to either the EGD-first group (n = 100) or the colonoscopy-first group (n = 100). Results: The EGD-first group required a longer cecal-intubation time (median 16.0 min vs. 13.7 min, p < 0.001) and a lower Boston Bowel Preparation Scale score (8.5 vs. 9, p = 0.030) compared with the colonoscopy-first group. However, the EGD-first group needed a significantly lower dose of propofol (200 mg vs. 250 mg, p < 0.001) and a shorter recovery time (7 min vs. 13.5 min, p < 0.001), resulting in a shorter turnover time of the endoscopy room (39.5 min vs. 42.6 min, p = 0.004). There were no differences in the sedation-related adverse events, patients’ satisfaction scores, adenoma-detection rates, or the outcomes of EGD between the two groups. Conclusions: During propofol-sedated BDE, EGD followed by WE colonoscopy was more efficient with a shorter turnover time despite a longer cecal-intubation time (NCT03638713).

Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer.

To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy.

This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA.

Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation.

Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years.

In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.

Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied.

To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days.

A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices.

Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated.

A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors.

Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

To determine the procedure-related factors that affect sedation satisfaction and to make a suggestion to improve it.

We prospectively enrolled a total of 456 patients who underwent outpatient endoscopy procedures with midazolam sedation between March 2014 and August 2014. All patients completed both pre- and post-endoscopy questionnaires about sedation expectations and satisfaction.

The study cohort included 167 (36.6%) patients who underwent esophagogastroduodenoscopy (EGD), 167 (36.6%) who underwent colonoscopy, and 122 (26.8%) who underwent a combined procedure (EGD and colonoscopy). Over 80% of all patients were satisfied with sedation using midazolam. In univariate and multivariate analyses, total procedure time in the EGD group, younger age (≤ 50 years), and longer colonoscopy withdrawal time in the colonoscopy group were related to decreased satisfaction with sedation. However, in active monitoring and intervention group, there was no decrease in grade of satisfaction despite longer procedure time due to more procedures during colonoscopy. Younger age (≤ 50 years), longer inter-procedure time gap, and colonoscopy withdrawal time were related to decreased satisfaction in the combined EGD and colonoscopy group.

Midazolam is still a safe and effective sedative for gastrointestinal endoscopy. Satisfaction with sedation depends on several factors including age (≤ 50 years) and procedure time duration. To improve patient satisfaction with sedation, active monitoring of sedation status by the endoscopist should be considered for patients who require long procedure time.

In epidemiological research, large datasets are essential to reliably capture small variations among comparative groups or detect new unsuspected associations. Although large databases of web-search information, social media, airline traffic and telephone records are already widely used to capture social trends, large databases in medical research are just emerging. With the universal use of electronic medical records underway, vast amounts of health-related information will become available for biomedical research. Accepting such new research tools-based on the analysis of large pre-existing datasets rather than hypothesis-driven, in-depth prospective study-will require a new mindset in clinical research, as data might be 'messy' and only associations, but not causality, can be detected. In spite of such limitations, the utilization of these new resources for medical research harbours great potential for advancing knowledge about digestive diseases.