Discussion

To the best of our knowledge, this is the first study to report 30-day mortality following GI endoscopies in a tertiary hospital. As mortality occurrence and date is linked to administrative civil registration, our study data are reliable. The mortality rate was low (1.89%) but more than twice as high as the 30-day mortality of all patients who went to the recovery room of our hospital after surgical or non-GI endoscopic procedures (0.8%). In our study, the majority of patients were elderly males with many comorbidities. Cirrhosis was one of the most frequent comorbidities along with hypertension and neoplasia. Alcohol consumption was frequent due to the higher risk for GI and liver pathologies. The highest mortality rate was observed after PEG insertion, mostly due to the patients’ comorbidities and the prognosis of the underlying disease, such as neurological diseases.

Of the 251 patients, no deaths were caused by haemorrhagic shock or GI tract perforation caused by the procedure. A proportion of the 66 deaths due to pneumonia, respiratory failure, myocardial infarction, cardiac arrest or cerebrovascular accident could have been precipitated by endoscopy or anaesthesia. However, due to the absence of a control group, this exact proportion is unknown.

Interestingly, neurological deaths and most cardiovascular deaths occurred within 10 days of the last procedure, and most of the pneumonia and respiratory failure deaths within 20 days. Twenty-two procedures of these 66 patients were elective due to the clinical stability of the patient or the non-urgent indication, suggesting that the procedure itself could have been a precipitating factor. One of the four patients who died of a cerebrovascular stroke had an anticoagulation withhold for an ERCP procedure.

In contrast to older12 publications and in line with more recent ones,13 14 cardiopulmonary deaths are less frequent compared with those associated with the progression of underlying malignancies. Preprocedural evaluation with improved knowledge of anaesthetic risks, intraprocedural and postprocedural patient monitoring could have contributed to this change.15 However, presence and availability of an anaesthesiologist and type of sedation is heterogeneous between countries and hospitals.16–18 Most frequently in Switzerland19 and in our hospital, endoscopists are solely responsible for anaesthesia and can use propofol for patients with ASA score 1 or 2 and low risk procedures. An anaesthesiologist is present for ASA scores 3 and 4 patients or for high-risk procedures such as foreign body removal or upper GI bleeding. In our study, due to high ASA scores and numerous critically ill patients, anaesthesia was undertaken by anaesthesiologists or intensivists in 80% of procedures. As anaesthesiologists cannot be present for all endoscopies, especially in private practice,16 careful preprocedural anaesthetic risk evaluation is mandatory. For ASA 1 and 2 scores patients, studies showed safe non-anaesthesiologist-administered propofol with no increase in cardiopulmonary events.17 19–21

New chemotherapies and immunotherapies that improve the prognosis of oncological patients could encourage us to perform invasive procedures later in the oncological course. By the definition, we used for the oncological cause of death, we excluded as much as possible patient who died from a procedure complication. However, for few causes such as pneumonia in pulmonary cancer or bacterial translocation in GI cancer, the procedure could have hastened the death. In our study, the diagnosis of malignancy was known before the endoscopy in 38/82 (46.34%) of patients who died of an oncological or haematological cause. Among them, 21/38 (55.26%) were at a metastatic stage. Thus, as described by other authors,22 some procedures could seem excessive or even futile as oncological mortality might reflect an expected disease progression. Similarly, we performed six endoscopies in four patients with ECMO or ECC. In such cases, patient survival depends mostly on the underlying disease and the selection of patients by intensivists and/or oncologists. Due to the existence of new therapeutics in non-GI specialties, it is becoming increasingly difficult for on-call GI physicians to evaluate and individualise the benefits of an endoscopy. This study highlights the role of the GI physician in informing patients and families about the risks and the importance of a multidisciplinary approach to select the patients who will benefit from a GI procedure, especially in oncology and geriatrics.

A remarkable aspect of our study is the proportion of incomplete colonoscopies due to insufficient bowel preparation. It has been described in previous studies and observed in the practice of every GI physician that old age, severe illness, hospitalisation and many comorbidities are risk factors for insufficient bowel preparation.23 In our study, the three most frequent causes of death after colonoscopy were congestive heart failure or myocardial infarction, cardiac arrest of unknown origin and pneumonia. As previously described, these causes point to the potentially deleterious effect of the procedure. Indeed, more than other procedures, the risk of colonoscopies frequently outweighs their benefit due to the proportion of non-contributive examinations in old or frail patients. For these patients, a CT colonography should be favoured to avoid anaesthetic risk. However, in our study, most frequent colonoscopy indications needed a potential therapeutic procedure (25 GI bleeding, 3 volvuli) or biopsies (2 colitis). For 13 tumourous suspicion indications, only 3 colonoscopies found a tumourous lesion, 3 had an insufficient bowel cleansing and 7 had no lesion. This suggests that CT colonography could have been used as a first step in those patients to avoid deleterious anaesthetic effect and select patient who have a higher benefit of colonoscopy for biopsies.

In previous data and according to a meta-analysis published in 2016, the pooled 30-day PEG mortality rate was reported to be 5.5%, which is similar to our data.24–26 In our unit, as shown by Stein et al,27 the 30-day mortality rate after PEG insertion has decreased in the last decade. In comparison, in 2011 and 2012 in our centre, 122 PEG were performed with a 30-day mortality rate of 8.96% (12/122) (personal data) compared with 3.05% in this study despite a stable number of PEG insertions (65.6 per year in 2017–2019 vs 67 per year in 2011–2012) and the use of the same insertion technique.26 The cause of this change remains elusive to us. It is most probably due to a better selection of patients and an improvement in the information given to our colleagues of other specialties as well as to patients and their families about the low benefit–risk ratio of PEG insertion in the presence of specific conditions such as dementia. In our hospital, nutrition team is usually not involved in the decision. Multidisciplinary discussion with nutritionist could further improve patient selection.

Mainly, indications for the procedures (table 3) are justified and reasonable. However, high number of comorbidities, proportion of incomplete colonoscopies and oncological progression as the leading cause of death suggest that selection of patients could be improved. As this study is undertaken in a tertiary hospital, it reflects a selection of patients who are frail and comorbid. However, death rate for other anaesthetic procedures (0.8%) including high risk cardiac, neurological and thoracic surgeries, is much lower than after GI procedures. Thus, to lower the postprocedural mortality in tertiary hospitals, patient selection could be the most efficient one. Now, prospective studies including all patients who undertake a GI procedure are needed to identify risk factors.

The main limitation of our study is its retrospective data collection and the absence of a control group. Due to its retrospective nature and the high number of other procedures, comparisons with patients who did not die were not possible. This feature reflects the complexity of recording mortality data in each hospital. Despite the relevance and recommendation regarding the collection of precise data on mortality as an indicator of quality standards for endoscopies, it is rarely performed due to the physicians’ lack of time and the high number of patients seen in GI units for short procedures. This highlights the necessity for hospitals to implement a system for the automatic collection of data in a prospective manner. Added to the retrospective manner, our data are subject to caution as the single centre setting can induce patient selection biases.

Another limitation is the small sample size for certain type of procedures. As our aim was to evaluate death during 3 years after every procedure, EUS and ERCP had a small occurrence of death. It is thus difficult to conclude on mortality after such procedures, and more studies are needed.

As mortality is a rare adverse event, especially in non-tertiary hospital, information about death causes is less useful for the majority of gastroenterologists in private practice. In other settings, other quality markers such as patient satisfaction, adenoma detection rate, unplanned adverse events and appropriateness of procedure indication should be used on daily basis.1 28

As our data are from a tertiary transplant hospital, they cannot be extrapolated to other practice settings. Given that patient deaths are mostly caused by underlying diseases, the mortality rate of GI endoscopies is strongly dependent on the expertise of other specialties. This study emphasises the difficulty of using the mortality rate as an indicator of quality standards.