Letters to the editor
Response:
Antibiotic prophylaxis for GI endoscopy
We appreciate the comments from Davinderbir Pannu et al regarding our study of the role of thoracic CT after peroral endoscopic myotomy (POEM) for the treatment of achalasia.1 They described a cohort of post-POEM patients who underwent CT esophagraphy on postoperative day 1. Overall, their results were in line with our findings that several CT results were not clinically significant and needed no intervention such as pneumomediastinum, pneumoperitoneum, pleural effusion, and subcutaneous emphysema. However, they were concerned that potentially serious adverse events like leakage may be initially asymptomatic and not clinically evident. Esophageal leakage is a rare and serious post-POEM adverse event, occurring in fewer than 0.2% of patients (3 of more than 1500 patients) in our center. We agree that early detection of esophageal leakage is very difficult in clinical practice. We have little experience with post-POEM fluoroscopic screening. A team in Hamburg, Werner et al (unpublished information), studied the value of postprocedural fluoroscopic screening with water-soluble contrast agent versus endoscopy in the early postoperative period. They concluded that endoscopy is superior to fluoroscopy with a water-soluble contrast agent in detecting minor defects at the entry site and minor lesions of the mucosa overlying the myotomy, although it is not comparable with CT esophagraphy, considering the cost effectiveness and the fact that CT esophagraphy is not available in many hospitals. We think that esophagraphy or CT esophagraphy should be reserved for patients with clinically suspected leakage. Leakage in some patients may be detected or symptomatic only after the start of oral intake. From our empirical view, we postpone postoperative food intake in any of the following scenarios: patients with thickening of the esophageal mucosa caused by food debris or recurrent inflammation, patients who had mucosal thermal damage or mucosal rupture during the POEM procedure, and patients who had unreliable mucosal entry closure. The risk factors of post-POEM esophageal leakage still need to be studied. Again, thank you for your interest in our study.
To the Editor:
Ming-Yan Cai, MD Ping-Hong Zhou, MD, PhD Li-Qing Yao, MD Endoscopy Center and Endoscopy Research Institute Zhongshan Hospital Fudan University Shanghai, China REFERENCES 1. Cai MY, Zhou PH, Yao LQ, et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014;80: 1046-55. http://dx.doi.org/10.1016/j.gie.2015.02.016
www.giejournal.org
We read with great interest the recent guideline for antibiotic prophylaxis in GI endoscopy produced by the American Society for Gastrointestinal Endoscopy1 in which the authors mentioned there were no results available that confidently quantify bacteremia rates with newer endoscopic procedures such as endoscopic submucosal dissection (ESD) or EMR. Therefore, the bacteremia associated with ESD or EMR was not discussed in this guideline. However, we searched the medical literature carefully and found 3 articles reporting the incidence of bacteremia after EMR or ESD for colorectal or gastric tumors. Itaba et al2 and Kato et al3 revealed the frequency of bacteremia after gastric ESD was low and transient. Min et al4 reported low frequency of bacteremia after an endoscopic resection for large colorectal tumors. In the 2 reports of gastric ESD, blood cultures obtained after ESD were positive in 4.3% (2/46) of cases (Bacillus subtilis and Bacillus spp were the isolated microorganisms)2 and 2% (1/50) of cases (Enterobacter aerogenes was the isolated microorganisms).3 In the setting of colonic ESD or EMR, blood culture after the procedure showed a positive result in 1 of 40 patients (2.5%), and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant.4 Furthermore, none of the patients showed any signs or symptoms associated with infection in the above studies. All 3 studies suggested that EMR or ESD carried a low risk for bacteremia and did not warrant prophylactic administration of antibiotics. These results may be a supplement of “Procedures associated with a low risk of bacteremia” part in the guideline of “Antibiotic prophylaxis for GI endoscopy.” However, further randomized controlled trials are warranted to elucidate the necessity for prophylactic antibiotic administration in EMR or ESD. Xiaowei Tang, MD Wei Gong, MD, PhD Bo Jiang, MD, PhD Department of Gastroenterology Nanfang Hospital Southern Medical University Guangzhou, China
REFERENCES 1. ASGE Standards of Practice Committee; Khashab MA, Chithadi KV, Acosta RD, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015;81:81-9. 2. Itaba S, Iboshi Y, Nakamura K, et al. Low-frequency of bacteremia after endoscopic submucosal dissection of the stomach. Dig Endosc 2011;23: 69-72.
Volume 81, No. 6 : 2015 GASTROINTESTINAL ENDOSCOPY 1503
Letters to the editor 3. Kato M, Kaise M, Obata T, et al. Bacteremia and endotoxemia after endoscopic submucosal dissection for gastric neoplasia: pilot study. Gastric Cancer 2012;15:15-20. 4. Min BH, Chang DK, Kim DU, et al. Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure. Gastrointest Endosc 2008;68:105-10. http://dx.doi.org/10.1016/j.gie.2015.01.021
administration of antibiotic prophylaxis solely for the prevention of infective endocarditis for all GI procedures, including EMR and ESD. We agree with them that larger, prospective trials in this burgeoning field are warranted to more fully inform endoscopists regarding the risk of bacteremia and infectious adverse events after EMR and/ or ESD.
Response: We appreciate the comments by Tang et al regarding the recent American Society for Gastrointestinal Endoscopy guideline on antibiotic prophylaxis for GI endoscopy.1 They identified and discussed 3 articles that reported a low incidence of bacteremia after either gastric or colonic EMR and/or endoscopic submucosal dissection (ESD), with no reported infectious adverse events in those with detectable bacteremia. Our guideline document summarized the key aspects of the medical literature on postprocedural risk of bacteremia, and we appreciate their identification of additional data demonstrating a low risk of bacteremia specifically subsequent to upper and lower GI EMR and/or ESD. The data highlighted by Tang et al support our recommendation against the routine
Mouen A. Khashab, MD Division of Gastroenterology and Hepatology Johns Hopkins Hospital Baltimore, Maryland Brooks D. Cash, MD Division of Gastroenterology University of South Alabama Mobile, Alabama, USA
REFERENCE 1. ASGE Standards of Practice Committee; Khashab MA, Chithadi KV, Acosta RD, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015;81:81-9. http://dx.doi.org/10.1016/j.gie.2015.03.1971
ERRATUM In the Letter to the Editor, “Development of an endosonography app: a smart device for continuous education,” in the May issue of Gastrointestinal Endoscopy (Gastrointest Endosc 2015;81:1299-1300), one author’s name was misspelled. The correct spelling appears below. Paul Fockens, MD, PhD, FASGE
1504 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 6 : 2015
www.giejournal.org
Response:
Antibiotic prophylaxis for GI endoscopy
We appreciate the comments from Davinderbir Pannu et al regarding our study of the role of thoracic CT after peroral endoscopic myotomy (POEM) for the treatment of achalasia.1 They described a cohort of post-POEM patients who underwent CT esophagraphy on postoperative day 1. Overall, their results were in line with our findings that several CT results were not clinically significant and needed no intervention such as pneumomediastinum, pneumoperitoneum, pleural effusion, and subcutaneous emphysema. However, they were concerned that potentially serious adverse events like leakage may be initially asymptomatic and not clinically evident. Esophageal leakage is a rare and serious post-POEM adverse event, occurring in fewer than 0.2% of patients (3 of more than 1500 patients) in our center. We agree that early detection of esophageal leakage is very difficult in clinical practice. We have little experience with post-POEM fluoroscopic screening. A team in Hamburg, Werner et al (unpublished information), studied the value of postprocedural fluoroscopic screening with water-soluble contrast agent versus endoscopy in the early postoperative period. They concluded that endoscopy is superior to fluoroscopy with a water-soluble contrast agent in detecting minor defects at the entry site and minor lesions of the mucosa overlying the myotomy, although it is not comparable with CT esophagraphy, considering the cost effectiveness and the fact that CT esophagraphy is not available in many hospitals. We think that esophagraphy or CT esophagraphy should be reserved for patients with clinically suspected leakage. Leakage in some patients may be detected or symptomatic only after the start of oral intake. From our empirical view, we postpone postoperative food intake in any of the following scenarios: patients with thickening of the esophageal mucosa caused by food debris or recurrent inflammation, patients who had mucosal thermal damage or mucosal rupture during the POEM procedure, and patients who had unreliable mucosal entry closure. The risk factors of post-POEM esophageal leakage still need to be studied. Again, thank you for your interest in our study.
To the Editor:
Ming-Yan Cai, MD Ping-Hong Zhou, MD, PhD Li-Qing Yao, MD Endoscopy Center and Endoscopy Research Institute Zhongshan Hospital Fudan University Shanghai, China REFERENCES 1. Cai MY, Zhou PH, Yao LQ, et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014;80: 1046-55. http://dx.doi.org/10.1016/j.gie.2015.02.016
www.giejournal.org
We read with great interest the recent guideline for antibiotic prophylaxis in GI endoscopy produced by the American Society for Gastrointestinal Endoscopy1 in which the authors mentioned there were no results available that confidently quantify bacteremia rates with newer endoscopic procedures such as endoscopic submucosal dissection (ESD) or EMR. Therefore, the bacteremia associated with ESD or EMR was not discussed in this guideline. However, we searched the medical literature carefully and found 3 articles reporting the incidence of bacteremia after EMR or ESD for colorectal or gastric tumors. Itaba et al2 and Kato et al3 revealed the frequency of bacteremia after gastric ESD was low and transient. Min et al4 reported low frequency of bacteremia after an endoscopic resection for large colorectal tumors. In the 2 reports of gastric ESD, blood cultures obtained after ESD were positive in 4.3% (2/46) of cases (Bacillus subtilis and Bacillus spp were the isolated microorganisms)2 and 2% (1/50) of cases (Enterobacter aerogenes was the isolated microorganisms).3 In the setting of colonic ESD or EMR, blood culture after the procedure showed a positive result in 1 of 40 patients (2.5%), and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant.4 Furthermore, none of the patients showed any signs or symptoms associated with infection in the above studies. All 3 studies suggested that EMR or ESD carried a low risk for bacteremia and did not warrant prophylactic administration of antibiotics. These results may be a supplement of “Procedures associated with a low risk of bacteremia” part in the guideline of “Antibiotic prophylaxis for GI endoscopy.” However, further randomized controlled trials are warranted to elucidate the necessity for prophylactic antibiotic administration in EMR or ESD. Xiaowei Tang, MD Wei Gong, MD, PhD Bo Jiang, MD, PhD Department of Gastroenterology Nanfang Hospital Southern Medical University Guangzhou, China
REFERENCES 1. ASGE Standards of Practice Committee; Khashab MA, Chithadi KV, Acosta RD, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015;81:81-9. 2. Itaba S, Iboshi Y, Nakamura K, et al. Low-frequency of bacteremia after endoscopic submucosal dissection of the stomach. Dig Endosc 2011;23: 69-72.
Volume 81, No. 6 : 2015 GASTROINTESTINAL ENDOSCOPY 1503
Letters to the editor 3. Kato M, Kaise M, Obata T, et al. Bacteremia and endotoxemia after endoscopic submucosal dissection for gastric neoplasia: pilot study. Gastric Cancer 2012;15:15-20. 4. Min BH, Chang DK, Kim DU, et al. Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure. Gastrointest Endosc 2008;68:105-10. http://dx.doi.org/10.1016/j.gie.2015.01.021
administration of antibiotic prophylaxis solely for the prevention of infective endocarditis for all GI procedures, including EMR and ESD. We agree with them that larger, prospective trials in this burgeoning field are warranted to more fully inform endoscopists regarding the risk of bacteremia and infectious adverse events after EMR and/ or ESD.
Response: We appreciate the comments by Tang et al regarding the recent American Society for Gastrointestinal Endoscopy guideline on antibiotic prophylaxis for GI endoscopy.1 They identified and discussed 3 articles that reported a low incidence of bacteremia after either gastric or colonic EMR and/or endoscopic submucosal dissection (ESD), with no reported infectious adverse events in those with detectable bacteremia. Our guideline document summarized the key aspects of the medical literature on postprocedural risk of bacteremia, and we appreciate their identification of additional data demonstrating a low risk of bacteremia specifically subsequent to upper and lower GI EMR and/or ESD. The data highlighted by Tang et al support our recommendation against the routine
Mouen A. Khashab, MD Division of Gastroenterology and Hepatology Johns Hopkins Hospital Baltimore, Maryland Brooks D. Cash, MD Division of Gastroenterology University of South Alabama Mobile, Alabama, USA
REFERENCE 1. ASGE Standards of Practice Committee; Khashab MA, Chithadi KV, Acosta RD, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015;81:81-9. http://dx.doi.org/10.1016/j.gie.2015.03.1971
ERRATUM In the Letter to the Editor, “Development of an endosonography app: a smart device for continuous education,” in the May issue of Gastrointestinal Endoscopy (Gastrointest Endosc 2015;81:1299-1300), one author’s name was misspelled. The correct spelling appears below. Paul Fockens, MD, PhD, FASGE
1504 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 6 : 2015
www.giejournal.org
