Gastroesophageal reflux disease after diagnostic endoscopy in the clinical setting

AIM: To investigate the outcome of patients with symptoms of gastroesophageal reflux disease (GERD) referred for endoscopy at 2 and 6 mo post endoscopy. METHODS: Consecutive patients referred for upper endoscopy for assessment of GERD symptoms at two large metropolitan hospitals were invited to participate in a 6-mo non-interventional (observational) study.The two institutions are situated in geographically and socially disparate areas. Data collection was by selfcompletion of questionnaires including the patient assessment of upper gastrointestinal disorders symptoms severity and from hospital records. Endoscopic finding using the Los-Angeles classification, symptom severity and it's clinically relevant improvement as change of at least 25%, therapy and socio-demographic factors were assessed. RESULTS: Baseline data were available for 266 patients and 2-mo and 6-mo follow-up data for 128 and 108 patients respectively. At baseline, 128 patients had erosive and 138 non-erosive reflux disease. Allmost all patient had proton pump inhibitor (PPI) therapy in the past. Overall, patients with non-erosive GERD at the index endoscopy had significantly more severe symptoms as compared to patients with erosive or even complicated GERD while there was no difference with regard to medication. After 2 and 6 mo there was a small, but statistically significant improvement in symptom severity (7.02 ± 5.5 vs 5.9 ± 5.4 and 5.5 ± 5.4 respectively); however, the majority of patients continued to have symptoms (i.e. , after 6 mo 81% with GERD symptoms). Advantaged socioeconomic status as well as being unemployed was associated with greater improvement. CONCLUSION: The majority of GORD patients receive PPI therapy before being referred for endoscopy even though many have symptoms that do not sufficiently respond to PPI therapy.

Non-physician endoscopists: A systematic review

AIM:To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal(GI) endoscopy services.METHODS:The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms.Studies were screened against eligibility criteria and for relevance.Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of nonphysician endoscopists.These publications included a total of 28883 procedures performed by non-physician endoscopists.RESULTS:The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter.17/26 studies related to flexible sigmoidoscopies,5 to upper GI endoscopy and 6 to colonoscopy.All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists.Geographic distribution of publications showed the majority of research was conducted in the United States(43%),the United Kingdom(39%)and the Netherlands(7%).Most studies conclude that after appropriate training nurseendoscopists safely perform procedures.However,in relation to endoscopic competency,safety or patient satisfaction,all studies had major methodological limitations.Patients were often not randomized(21/26studies)and not appropriately controlled.In relation to cost-efficiency,nurse endoscopists were less costeffective per procedure at year 1 when compared to services provided by physicians,due largely to the increased need for subsequent endoscopies,specialist follow-up and primary care consultations.CONCLUSION:Contrary to general beliefs,endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite.Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.