Falling Down the Rabbit Hole of Irrational Endoscopy Requests

Excerpt

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. …