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Adverse events associated with EGD and EGD-related techniques

      Abbreviations:

      AE (adverse event), ASGE (American Society for Gastrointestinal Endoscopy), CI (confidence interval), EoE (eosinophilic esophagitis), PEJ (percutaneous endoscopic jejunostomy), SEMS (self-expanding metal stent)
      This document is intended to educate readers on the rates and predictors of adverse events (AEs) in patients who undergo EGD and EGD-related techniques. Our goal is to assist endoscopists in providing accurate, evidence-based, and up-to-date information on the rates of AEs to patients, caretakers, and trainees. The information provided should not be construed as encouraging or discouraging any particular treatment or technique. Clinical decision-making in any specific case involves a personalized and thorough analysis of the patient’s condition, available courses of action, local expertise, and the patient’s values and preferences. Therefore, certain clinical considerations could lead an endoscopist to take a course of action that varies from the guidance in this document. This document is an update of a previous guideline prepared by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) in 2013.
      • Early D.S.
      • Acosta R.D.
      • Chandrasekhara V.
      • et al.
      Adverse events associated with EUS and EUS with FNA.
      EGD or upper GI endoscopy is one of the most commonly performed GI procedures, with annual volumes exceeding 7.4 million in the United States.
      • Peery A.F.
      • Crockett S.D.
      • Murphy C.C.
      • et al.
      Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021.
      Accurate estimates of the AE rates associated with the performance of EGD are difficult to summarize because of several limitations encountered in source data. Such limitations include variability in data collection and outcome definitions, inconsistent follow-up periods, and reliance on self-reporting, among others.
      • Ben-Menachem T.
      • Decker G.A.
      • Early D.S.
      • et al.
      Adverse events of upper GI endoscopy.
      Despite these limitations, diagnostic EGD has generally been considered a safe procedure.
      • Ben-Menachem T.
      • Decker G.A.
      • Early D.S.
      • et al.
      Adverse events of upper GI endoscopy.
      However, because of increasing patient complexity and constant evolution in therapeutic endoscopic techniques, contemporary updates to estimates of risk associated with EGD are necessary. This document provides a review of commonly encountered potential AEs associated with EGD and EGD-related techniques.

      Methods

      A comprehensive electronic database search was executed with the help of an expert medical librarian. The search was designed to capture AEs associated with diagnostic EGD with or without biopsy sampling, EGD with management of foreign body impaction, EGD with dilation and/or stent placement, EGD with hemostasis, and EGD with placement of percutaneous gastric or enteral access. Other therapeutic maneuvers including EMR, endoscopic submucosal dissection,
      • Evans J.A.
      • Early D.S.
      • Chandrasekhara V.
      • et al.
      ASGE Standards of Practice Committee
      The role of endoscopy in the assessment and treatment of esophageal cancer.
      radiofrequency ablation,
      • Wani S.
      • Qumseya B.
      • Sultan S.
      • et al.
      ASGE Standards of Practice Committee
      Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer.
      endoscopic suturing, peroral endoscopic myotomy,
      • Khashab M.A.
      • Vela M.F.
      • Thosani N.
      • et al.
      ASGE guideline on the management of achalasia.
      antireflux endoscopy, and bariatric endoscopy
      • Evans J.A.
      • Muthusamy V.R.
      • Acosta R.D.
      • et al.
      American Society for Gastrointestinal Endoscopy Standards of Practice Committee
      The role of endoscopy in the bariatric surgery patient.
      were not intended to be captured in this review, because of relative novelty of and/or widespread lack of familiarity with the technique or because of discussion in detail of the technique(s) in more relevant ASGE documents.
      An electronic search was performed in PubMed and MEDLINE (Ovid) for English-language citations of prospective, retrospective, and relevant studies published from 1966 to January 7, 2021 using the search methods detailed in Appendix 1 (available online at www.giejournal.org). In addition, we solicited expert endoscopists for any relevant studies published up to and beyond this date. All citations initially identified were imported into Covidence (Covidence, Melbourne, Australia), and all duplicates were removed. In parallel, bibliographies of selected citations were searched, ad hoc supplementary PubMed database searches were performed, and experts were consulted for any potential studies not identified by the electronic strategy.
      Studies were considered for inclusion if they reported the rates of any AE(s) during or after performance of EGD. Studies were generally considered for inclusion based on design, in the descending order of strength of evidence: systematic review and meta-analyses, randomized controlled trials, prospective observational studies, retrospective observational studies, and case series or reports, with study size, study quality, and publication date factoring into the decision. In the first round of screening, an author (N.C.-P.) screened titles and abstracts and assigned studies to a designation of “possibly include” or “exclude” considering the above criteria. Any abstract labeled with the decision to possibly include was included in the second round. After the title and abstract screen, we made the decision on whether to cite studies included in the second round in the final review document based on the above criteria. Data on AEs were then extracted from the full-text studies selected for inclusion and presented according to each EGD-related procedure type.

      Results

      The electronic search yielded 4623 initial citations after removal of duplicates. A review of the evidence for each major AE type is provided below, with a summary of AE rates provided in Table 1. Predictors of AEs were also synthesized and reported wherever possible.
      Table 1Summary of estimated common adverse event ranges for EGD, based on results from relevant studies
      EGD typeBleedingPerforationInfectionOtherRisk factors for adverse events
      Diagnostic<.1%
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      <.01%
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      ,
      • Johnson B.
      • Basson M.D.
      Absence of complications after endoscopic mucosal biopsy.
      <.3%
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      ,
      • Nelson D.B.
      Infectious disease complications of GI endoscopy: Part I, endogenous infections.
      Cardiopulmonary:

      <.1%
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      ,
      • Goudra B.
      • Nuzat A.
      • Singh P.M.
      • et al.
      Association between type of sedation and the adverse events associated with gastrointestinal endoscopy: an analysis of 5 years' data from a tertiary center in the USA.
      • Jun J.
      • Han J.I.
      • Choi A.L.
      • et al.
      Adverse events of conscious sedation using midazolam for gastrointestinal endoscopy.
      • Alshamsi F.
      • Jaeschke R.
      • Baw B.
      • et al.
      Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: a systematic review and meta-analysis.
      • Olaiya B.
      • Adler D.G.
      Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013).
      • Donepudi S.
      • Chavalitdhamrong D.
      • Pu L.
      • et al.
      Air embolism complicating gastrointestinal endoscopy: a systematic review.
      Bleeding: age ≥65 y
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.


      Infection: preceding hospitalization, preceding endoscopy, lower facility procedural volume
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.


      Cardiopulmonary: age ≥65 y, obesity, hypertension, diabetes, coronary artery disease, recent acute myocardial infarction
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      ,
      • Benson M.
      • Hubers J.
      • Caldis M.
      • et al.
      Safety and efficacy of moderate sedation in super obese patients undergoing lower and upper GI endoscopy: a case-control study.
      • Long Y.
      • Liu H.H.
      • Yu C.
      • et al.
      Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy.
      • Cena M.
      • Gomez J.
      • Alyousef T.
      • et al.
      Safety of endoscopic procedures after acute myocardial infarction: a systematic review.
      • Enestvedt B.K.
      • Eisen G.M.
      • Holub J.
      • et al.
      Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?.
      Management of foreign body or food impaction2.6%
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      .4%-3.3%
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      ,
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      ,
      • Park J.H.
      • Park C.H.
      • Park J.H.
      • et al.
      Review of 209 cases of foreign bodies in the upper gastrointestinal tract and clinical factors for successful endoscopic removal.
      • Schupack D.A.
      • Lenz C.J.
      • Geno D.M.
      • et al.
      The evolution of treatment and complications of esophageal food impaction.
      • Sung S.H.
      • Jeon S.W.
      • Son H.S.
      • et al.
      Factors predictive of risk for complications in patients with oesophageal foreign bodies.
      • Weinstock L.B.
      • Shatz B.A.
      • Thyssen S.E.
      Esophageal food bolus obstruction: evaluation of extraction and modified push techniques in 75 cases.
      Aspiration pneumonia:

      1.8%-6.0%
      • Sengupta N.
      • Tapper E.B.
      • Corban C.
      • et al.
      The clinical predictors of aetiology and complications among 173 patients presenting to the emergency department with oesophageal food bolus impaction from 2004-2014.
      ,
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      Cardiopulmonary:

      1.5%-4.4%
      • Ikenberry S.O.
      • Jue T.L.
      • Anderson M.A.
      • et al.
      Management of ingested foreign bodies and food impactions.
      ,
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      Bleeding: no use of cap-assisted technique
      • Ooi M.
      • Duong T.
      • Holman R.
      • et al.
      Comparison of cap-assisted vs conventional endoscopic technique for management of food bolus impaction in the esophagus: results of a multicenter randomized controlled trial.


      Perforation: esophageal location, longer time from impaction to EGD, foreign body size, bone
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      ,
      • Park J.H.
      • Park C.H.
      • Park J.H.
      • et al.
      Review of 209 cases of foreign bodies in the upper gastrointestinal tract and clinical factors for successful endoscopic removal.
      ,
      • Sung S.H.
      • Jeon S.W.
      • Son H.S.
      • et al.
      Factors predictive of risk for complications in patients with oesophageal foreign bodies.
      DilationEsophageal:

      .1%-0.7%
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      ,
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      ,
      • Moawad F.J.
      • Molina-Infante J.
      • Lucendo A.J.
      • et al.
      Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.
      ,
      • Moole H.
      • Jacob K.
      • Duvvuri A.
      • et al.
      Role of endoscopic esophageal dilation in managing eosinophilic esophagitis: a systematic review and meta-analysis.
      ,
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.


      Gastroduodenal:

      0.7%-7.0%
      • Kochhar R.
      • Malik S.
      • Gupta P.
      • et al.
      Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.
      • Maus M.K.
      • Leers J.
      • Herbold T.
      • et al.
      Gastric outlet obstruction after esophagectomy: retrospective analysis of the effectiveness and safety of postoperative endoscopic pyloric dilatation.
      • Bettenworth D.
      • Mücke M.M.
      • Lopez R.
      • et al.
      Efficacy of endoscopic dilation of gastroduodenal Crohn's disease strictures: a systematic review and meta-analysis of individual patient data.


      Postsurgical:

      .1%-1.5%
      • Baumann A.J.
      • Mramba L.K.
      • Hawkins R.B.
      • et al.
      Endoscopic dilation of bariatric RNY anastomotic strictures: a systematic review and meta-analysis.
      ,
      • Chang S.H.
      • Popov V.B.
      • Thompson C.C.
      Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis.
      ,
      • de Moura E.G.H.
      • Orso I.R.B.
      • Aurélio E.F.
      • et al.
      Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery.
      Esophageal:

      .1%-.7%
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      ,
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      ,
      • Goyal A.
      • Chatterjee K.
      • Yadlapati S.
      • et al.
      Health-care utilization and complications of endoscopic esophageal dilation in a national population.
      ,
      • Grooteman K.V.
      • Wong Kee Song L.M.
      • Vleggaar F.P.
      • et al.
      Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.


      Pneumatic:

      2.0%-5.0%
      • van Hoeij F.B.
      • Prins L.I.
      • Smout A.
      • et al.
      Efficacy and safety of pneumatic dilation in achalasia: a systematic review and meta-analysis.
      • Bonifácio P.
      • de Moura D.T.H.
      • Bernardo W.M.
      • et al.
      Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials.
      • Ghoshal U.C.
      • Karyampudi A.
      • Verma A.
      • et al.
      Perforation following pneumatic dilation of achalasia cardia in a university hospital in northern India: a two-decade experience.
      • Katzka D.A.
      • Castell D.O.
      An analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia [Review].


      Gastroduodenal:

      1.5%-1.8%
      • Kochhar R.
      • Malik S.
      • Gupta P.
      • et al.
      Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.
      ,
      • Bettenworth D.
      • Mücke M.M.
      • Lopez R.
      • et al.
      Efficacy of endoscopic dilation of gastroduodenal Crohn's disease strictures: a systematic review and meta-analysis of individual patient data.


      Postsurgical:

      .5%-2.3%
      • Baumann A.J.
      • Mramba L.K.
      • Hawkins R.B.
      • et al.
      Endoscopic dilation of bariatric RNY anastomotic strictures: a systematic review and meta-analysis.
      ,
      • Chang S.H.
      • Popov V.B.
      • Thompson C.C.
      Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis.
      ,
      • de Moura E.G.H.
      • Orso I.R.B.
      • Aurélio E.F.
      • et al.
      Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery.
      Not reportedNot applicableBleeding: male sex, Barrett’s esophagus, malignancy, caustic strictures
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      ,
      • Kochhar R.
      • Malik S.
      • Gupta P.
      • et al.
      Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.


      Perforation: male sex, age ≥70 y, head and neck malignancy, corrosive injury
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      ,
      • Goyal A.
      • Chatterjee K.
      • Yadlapati S.
      • et al.
      Health-care utilization and complications of endoscopic esophageal dilation in a national population.
      • Grooteman K.V.
      • Wong Kee Song L.M.
      • Vleggaar F.P.
      • et al.
      Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.
      • Hagel A.F.
      • Naegel A.
      • Dauth W.
      • et al.
      Perforation during esophageal dilatation: a 10-year experience.
      • Moss W.J.
      • Pang J.
      • Orosco R.K.
      • et al.
      Esophageal dilation in head and neck cancer patients: a systematic review and meta-analysis.
      • Chiu Y.C.
      • Liang C.M.
      • Tam W.
      • et al.
      The effects of endoscopic-guided balloon dilations in esophageal and gastric strictures caused by corrosive injuries.
      Stent placementEsophageal:

      1.3%-3.7%
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      ,
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.


      Gastroduodenal:

      .8%-1.5%
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      ,
      • Costamagna G.
      • Tringali A.
      • Spicak J.
      • et al.
      Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: an international prospective multicentre registry.
      Esophageal:

      .9%-1.2%
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      ,
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      ,
      • Chandan S.
      • Mohan B.P.
      • Khan S.R.
      • et al.
      Clinical efficacy and safety of palliative esophageal stenting without fluoroscopy: a systematic review and meta-analysis.


      Gastroduodenal:

      1.2%-1.4%
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.
      ,
      • Ratone J.P.
      • Caillol F.
      • Zemmour C.
      • et al.
      Outcomes of duodenal stenting: experience in a French tertiary center with 220 cases.
      Aspiration pneumonia:

      .5%-2.5%
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      ,
      • Ratone J.P.
      • Caillol F.
      • Zemmour C.
      • et al.
      Outcomes of duodenal stenting: experience in a French tertiary center with 220 cases.
      Esophageal:

      4.1%-12.2% (migration, cancer),
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      ,
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.


      28.6% (migration, benign),
      • Fuccio L.
      • Hassan C.
      • Frazzoni L.
      • et al.
      Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.


      2.4%-12.4% (occlusion)
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      ,
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.


      Gastroduodenal:

      4.3% (migration),
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.


      12.6% (occlusion)
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.
      ,
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      Stent migration: covered stents,
      • Wang C.
      • Wei H.
      • Li Y.
      Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis.
      stent for benign disease
      • Fuccio L.
      • Hassan C.
      • Frazzoni L.
      • et al.
      Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.


      Stent occlusion: uncovered stents
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.
      Hemostasis or prophylaxis of bleeding1.4% (with gluing)
      • Guo Y.W.
      • Miao H.B.
      • Wen Z.F.
      • et al.
      Procedure-related complications in gastric variceal obturation with tissue glue.
      Not reportedAspiration pneumonia (with balloon tamponade):

      11.2%
      • Rodrigues S.G.
      • Cárdenas A.
      • Escorsell À.
      • et al.
      Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis.
      Fever (with gluing):

      35.0%
      • Ríos Castellanos E.
      • Seron P.
      • Gisbert J.P.
      • et al.
      Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension.


      Stent migration (with variceal bleed):

      23.8%
      • Rodrigues S.G.
      • Cárdenas A.
      • Escorsell À.
      • et al.
      Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis.


      Dysphagia or chest pain (with endoscopic band ligation):

      6.0%-23.0%
      • Rodrigues S.G.
      • Cárdenas A.
      • Escorsell À.
      • et al.
      Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis.
      Not reported
      PEG or percutaneous endoscopic jejunostomyPEG:

      .6%-2.6%
      • McClave S.A.
      • Chang W.K.
      Complications of enteral access.
      ,
      • Yuan T.W.
      • He Y.
      • Wang S.B.
      • et al.
      Technical success rate and safety of radiologically inserted gastrostomy versus percutaneous endoscopic gastrostomy in motor neuron disease patients undergoing: a systematic review and meta-analysis.
      ,
      • Lucendo A.J.
      • Sánchez-Casanueva T.
      • Redondo O.
      • et al.
      Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis.
      ,
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.


      Percutaneous endoscopic jejunostomy:

      .0%-2.4%
      • Lim A.H.
      • Schoeman M.N.
      • Nguyen N.Q.
      Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort.
      ,
      • Strong A.T.
      • Sharma G.
      • Davis M.
      • et al.
      Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement: a single institution experience and outcomes to 30 days and beyond.
      PEG:

      .2%-.8%
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.
      ,
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Comparative safety of endoscopic vs radiological gastrostomy tube placement: outcomes from a large, nationwide Veterans Affairs database.
      Site infection:

      1.7%-3.4%
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.
      ,
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Comparative safety of endoscopic vs radiological gastrostomy tube placement: outcomes from a large, nationwide Veterans Affairs database.


      Aspiration pneumonia:

      1.7%
      • Strong A.T.
      • Sharma G.
      • Davis M.
      • et al.
      Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement: a single institution experience and outcomes to 30 days and beyond.
      ,
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      Fever:

      3.5%
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      Bleeding: obesity, diabetes
      • Wiggins T.F.
      • Garrow D.A.
      • DeLegge M.H.
      Evaluation of percutaneous endoscopic feeding tube placement in obese patients.
      ,
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.


      Cellulitis: obesity
      • Wiggins T.F.
      • Garrow D.A.
      • DeLegge M.H.
      Evaluation of percutaneous endoscopic feeding tube placement in obese patients.
      ,
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.

      Diagnostic EGD

      Bleeding

      Clinically significant bleeding according to the ASGE lexicon (defined as a hemoglobin drop >2 g/dL and/or evidence of hematemesis, melena, or hematochezia)
      • Cotton P.B.
      • Eisen G.M.
      • Aabakken L.
      • et al.
      A lexicon for endoscopic adverse events: report of an ASGE workshop.
      is rare after diagnostic EGD either with or without biopsy sampling. In a 2021 nationwide retrospective claims data analysis of over 380,000 patients who underwent diagnostic EGD, bleeding requiring emergency department visit or inpatient stay occurred at a rate of 80 in 100,000 patients within 30 days of the index procedure.
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      A potential etiology is Mallory-Weiss tears caused by either direct trauma from the endoscope or retching during the procedure.
      • Montalvo R.D.
      • Lee M.
      Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy.
      The subgroup of patients aged ≥65 years has been correlated with an increased risk of bleeding (.05% vs .17%, P < .001).
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      Although intraprocedural bleeding has been observed in up to 2% to 6% of patients undergoing EGD while on continued antithrombotic therapy,
      • Yabe K.
      • Horiuchi A.
      • Kudo T.
      • et al.
      Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy.
      ,
      • Fujita M.
      • Shiotani A.
      • Murao T.
      • et al.
      Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics.
      this outcome is generally believed to be of limited clinical significance given that it does not usually alter a patient’s clinical trajectory.
      • Yabe K.
      • Horiuchi A.
      • Kudo T.
      • et al.
      Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy.
      Importantly, the available body of evidence suggests no significant differences in clinically relevant delayed bleeding between patients undergoing diagnostic EGD who do or do not take antithrombotic agents.
      • Yabe K.
      • Horiuchi A.
      • Kudo T.
      • et al.
      Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy.
      • Fujita M.
      • Shiotani A.
      • Murao T.
      • et al.
      Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics.
      • Bozkurt H.
      • Ölmez T.
      • Bulut C.
      • et al.
      The safety of upper gastrointestinal endoscopic biopsy in patients receiving antithrombic drugs. A single-centre prospective observational study.
      • Heublein V.
      • Pannach S.
      • Daschkow K.
      • et al.
      Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry.
      • Ara N.
      • Iijima K.
      • Maejima R.
      • et al.
      Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan.
      Also of note, in patients taking antithrombotic agents at baseline, available evidence suggests no differences in clinically significant bleeding outcomes when EGD (with or without biopsy sampling) is performed after appropriate periprocedural cessation of these agents
      • Acosta R.D.
      • Abraham N.S.
      • Chandrasekhara V.
      • et al.
      ASGE Standards of Practice Committee
      The management of antithrombotic agents for patients undergoing GI endoscopy.
      versus when they are continued leading up to and after the procedure.
      • Yabe K.
      • Horiuchi A.
      • Kudo T.
      • et al.
      Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy.
      ,
      • Kono Y.
      • Matsubara M.
      • Toyokawa T.
      • et al.
      Multicenter prospective study on the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users.
      ,
      • Yuki T.
      • Ishihara S.
      • Yashima K.
      • et al.
      Bleeding risk related to upper gastrointestinal endoscopic biopsy in patients receiving antithrombotic therapy: a multicenter prospective observational study.
      Based on these and other data, the ASGE guideline on management of antithrombotic agents concludes that there is a low overall risk of bleeding during diagnostic EGD with or without biopsy sampling in patients on all antithrombotic medication.
      • Acosta R.D.
      • Abraham N.S.
      • Chandrasekhara V.
      • et al.
      ASGE Standards of Practice Committee
      The management of antithrombotic agents for patients undergoing GI endoscopy.

      Perforation

      Perforation is an extremely rare AE of diagnostic EGD. In the same nationwide retrospective claims-based analysis of over 380,000 patients having undergone diagnostic EGD, perforation occurred at a rate of 1 in 25,000.
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      Similarly, in a 2018 retrospective analysis of over 13,000 EGDs with biopsy sampling, no perforations occurred within 30 days of the index procedure.
      • Johnson B.
      • Basson M.D.
      Absence of complications after endoscopic mucosal biopsy.
      These contemporary estimates are similar in magnitude but even more encouraging than prior estimates of perforation risk ranging between 1 in 2500 and 1 in 11,000
      • Ben-Menachem T.
      • Decker G.A.
      • Early D.S.
      • et al.
      Adverse events of upper GI endoscopy.
      that were based on considerably older studies.
      • Sieg A.
      • Hachmoeller-Eisenbach U.
      • Eisenbach T.
      Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.
      ,
      • Quine M.A.
      • Bell G.D.
      • McCloy R.F.
      • et al.
      Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England.

      Infection

      In the most comprehensive study assessing the risk of clinically significant infection after EGD, a 2018 claims-based analysis of over 870,000 EGDs performed across 6 states reported unplanned emergency department visits or hospital admissions for infection within 7 days of the index procedure in .3% of patients.
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      Of these, respiratory infections including aspiration pneumonia were most common, occurring in .16% of patients.
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      The rate of bacteremia after EGD was 1 in 1500, whereas rates of GI and genitourinary infections were both less than 1 in 2000.
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      Endocarditis after EGD was also noted to occur at a rate of 1 in 140,000 patients in this study,
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      with rare cases having previously been reported.
      • Nelson D.B.
      Infectious disease complications of GI endoscopy: Part I, endogenous infections.
      Prior hospitalization, prior endoscopy (compared with noninvasive screening mammography or prostate cancer screening), and lower facility procedural volumes each independently predicted higher rates of infection.
      • Wang P.
      • Xu T.
      • Ngamruengphong S.
      • et al.
      Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.
      Although the risk of endoscope-to-patient infectious transmission has become an increasing concern for duodenoscopes and linear echoendoscopes because of their designs, among other factors,
      • Forbes N.
      • Heitman S.J.
      • McCulloch P.
      Infection control in endoscopic retrograde cholangiopancreatography: a human factors perspective.
      ,
      • Rauwers A.W.
      • Voor In 't Holt A.F.
      • Buijs J.G.
      • et al.
      Nationwide risk analysis of duodenoscope and linear echoendoscope contamination.
      EGD procedures are not believed to carry a high risk of this AE.
      • Nelson D.B.
      • Barkun A.N.
      • Block K.P.
      • et al.
      Technology status evaluation report. Transmission of infection by gastrointestinal endoscopy.
      7

      Cardiopulmonary AEs

      As mentioned in earlier the ASGE guidelines, cardiopulmonary AEs include hypoxia, hypotension, cardiac dysrhythmia, and aspiration.
      • Chandrasekhara V.
      • Khashab M.A.
      • Muthusamy V.R.
      • et al.
      ASGE Standards of Practice Committee
      Adverse events associated with ERCP.
      Despite efforts to standardize reporting of cardiopulmonary AEs with endoscopy, few studies use these definitions.
      • Cotton P.B.
      • Eisen G.M.
      • Aabakken L.
      • et al.
      A lexicon for endoscopic adverse events: report of an ASGE workshop.
      Transient episodes of hypoxia or hypotension may not be reported because they are not considered clinically significant. Although physiologic variations in response to diagnostic EGD, sedation, and/or anesthesia are usually mild and transient, the rate of serious cardiopulmonary AEs during or after EGD is low. In a nationwide retrospective claims-based analysis of over 380,000 patients undergoing diagnostic EGD, acute myocardial infarction and congestive heart failure occurred at rates of 1 in 2300 and 1 in 6700 patients, respectively, within 30 days of the index procedure.
      • Kim H.I.
      • Yoon J.Y.
      • Kwak M.S.
      • et al.
      Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      In a single-center retrospective analysis of 31,441 diagnostic EGDs, cardiorespiratory arrest (defined as requiring chest compressions) occurred at a rate of 1 in 2200 patients.
      • Goudra B.
      • Nuzat A.
      • Singh P.M.
      • et al.
      Association between type of sedation and the adverse events associated with gastrointestinal endoscopy: an analysis of 5 years' data from a tertiary center in the USA.
      In a 2019 retrospective study including over 87,000 procedures with patients under conscious sedation, intraprocedural hypoxia, defined as any oxygen saturation <90%, occurred in .08% of patients.
      • Jun J.
      • Han J.I.
      • Choi A.L.
      • et al.
      Adverse events of conscious sedation using midazolam for gastrointestinal endoscopy.
      However, the clinical significance of isolated transient oxygen desaturations during endoscopy is uncertain. Although aspiration pneumonia is always of concern during diagnostic or therapeutic EGD, evidence assessing the rate of aspiration events is scarce outside of studies assessing acute GI bleeding.
      • Alshamsi F.
      • Jaeschke R.
      • Baw B.
      • et al.
      Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: a systematic review and meta-analysis.
      Air embolism is a rare but potentially fatal AE of EGD that has been described and warrants awareness,
      • Olaiya B.
      • Adler D.G.
      Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013).
      ,
      • Donepudi S.
      • Chavalitdhamrong D.
      • Pu L.
      • et al.
      Air embolism complicating gastrointestinal endoscopy: a systematic review.
      especially if air (rather than carbon dioxide) insufflation is used intraprocedurally.
      Predictors of periendoscopic cardiopulmonary AEs are as follows:
      • Age ≥65 years.
        • Kim H.I.
        • Yoon J.Y.
        • Kwak M.S.
        • et al.
        Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
      • Obesity.
        • Benson M.
        • Hubers J.
        • Caldis M.
        • et al.
        Safety and efficacy of moderate sedation in super obese patients undergoing lower and upper GI endoscopy: a case-control study.
        ,
        • Long Y.
        • Liu H.H.
        • Yu C.
        • et al.
        Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy.
      • Hypertension.
        • Long Y.
        • Liu H.H.
        • Yu C.
        • et al.
        Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy.
      • Diabetes.
        • Long Y.
        • Liu H.H.
        • Yu C.
        • et al.
        Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy.
      • Coronary artery disease,
        • Kim H.I.
        • Yoon J.Y.
        • Kwak M.S.
        • et al.
        Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
        ,
        • Long Y.
        • Liu H.H.
        • Yu C.
        • et al.
        Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy.
        in particular, EGD performed within 30 days of an acute myocardial infarction is associated with increased cardiopulmonary AEs of 1% to 8%, with most AEs being transient and/or mild.
        • Cena M.
        • Gomez J.
        • Alyousef T.
        • et al.
        Safety of endoscopic procedures after acute myocardial infarction: a systematic review.
      • Higher American Society of Anesthesiologists scores, which have been correlated with greater risk of serious AEs after EGD, with odds ratios (ORs) of 1.54 (95% confidence interval [CI], 1.31-1.82), 3.90 (95% CI, 3.27-4.64), and 12.02 (95% CI, 9.62-15.01) for scores of II, III, and IV/V, respectively.
        • Enestvedt B.K.
        • Eisen G.M.
        • Holub J.
        • et al.
        Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?.
      • Monitored anesthesia care, which has been correlated with a higher risk (.09% vs 0%, P < .05) of cardiorespiratory arrest compared with conscious sedation, although this may be confounded by patient selection.
        • Goudra B.
        • Nuzat A.
        • Singh P.M.
        • et al.
        Association between type of sedation and the adverse events associated with gastrointestinal endoscopy: an analysis of 5 years' data from a tertiary center in the USA.
      Although obstructive sleep apnea has been postulated to be associated with a higher risk of cardiopulmonary AEs, a meta-analysis of over 3000 patients did not demonstrate this as a risk factor.
      • Andrade C.M.
      • Patel B.
      • Vellanki M.
      • et al.
      Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea.
      The addition of capnography to standard monitoring has been shown to significantly reduce the incidence of clinically significant hypoxemia (OR, .53; 95% CI, .35-.81) in a meta-analysis including 3088 patients.
      • Kim S.H.
      • Park M.
      • Lee J.
      • et al.
      The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis.
      Endoscopists and anesthesiologists should be aware of these risk factors when performing EGD and should counsel their patients accordingly.

      EGD with Management of Foreign Body and/or Impaction

      Overview

      GI foreign bodies and/or impactions frequently require urgent or emergent EGD.
      • Ikenberry S.O.
      • Jue T.L.
      • Anderson M.A.
      • et al.
      Management of ingested foreign bodies and food impactions.
      Given that obstructions and impactions occur most often at sites of angulation or narrowing,
      • Ikenberry S.O.
      • Jue T.L.
      • Anderson M.A.
      • et al.
      Management of ingested foreign bodies and food impactions.
      mucosal tears, ulcerations, and/or full-thickness perforations resulting from the ingested foreign body itself are all possible. They are, in fact, more common than AEs attributable to the performance of EGD, occurring in up to 15% of cases.
      • Marashi Nia S.F.
      • Aghaie Meybodi M.
      • Sutton R.
      • et al.
      Outcome, complication and follow-up of patients with esophageal foreign body impaction: an academic institute's 15 years of experience.
      ,
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      Aspiration and respiratory compromise are also possible. Therefore, a thorough clinical evaluation for signs of any evidence of respiratory compromise is crucial before attempting to perform upper endoscopy. Furthermore, care should be taken during endoscopic evaluation and management of impactions, given that 80% of presenting patients will have an underlying lesion or condition such as a ring, eosinophilic esophagitis (EoE), strictures (benign or malignant), or a mass.
      • Sengupta N.
      • Tapper E.B.
      • Corban C.
      • et al.
      The clinical predictors of aetiology and complications among 173 patients presenting to the emergency department with oesophageal food bolus impaction from 2004-2014.

      Bleeding

      In a large retrospective analysis of over 900 patients with ingested foreign bodies, the rate of bleeding was 2.6%, with almost all of these being self-limited.
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      In this study, the use of a through-the-scope instrument (rather than using the push technique, in which gentle central pressure is applied to a soft bolus in the absence of significant resistance to displace it distally) was associated with a higher rate of periprocedural AEs, including bleeding.
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      However, this may possibly be a reflection of larger foreign bodies requiring the use of such instruments. In a recent multicenter randomized trial of 342 patients with food bolus impactions, the use of a soft, oblique, cap-assisted approach was associated with a significantly lower risk of mucosal tears and bleeding compared with a conventional approach (.0% vs 7.6%).
      • Ooi M.
      • Duong T.
      • Holman R.
      • et al.
      Comparison of cap-assisted vs conventional endoscopic technique for management of food bolus impaction in the esophagus: results of a multicenter randomized controlled trial.

      Perforation

      The risk of perforation during endoscopic management of impactions or obstructions appears to be highest in the esophagus compared with the stomach or small intestine.
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      Several retrospective studies reported rates of perforation from .4% to 3.3%.
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      ,
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      ,
      • Park J.H.
      • Park C.H.
      • Park J.H.
      • et al.
      Review of 209 cases of foreign bodies in the upper gastrointestinal tract and clinical factors for successful endoscopic removal.
      • Schupack D.A.
      • Lenz C.J.
      • Geno D.M.
      • et al.
      The evolution of treatment and complications of esophageal food impaction.
      • Sung S.H.
      • Jeon S.W.
      • Son H.S.
      • et al.
      Factors predictive of risk for complications in patients with oesophageal foreign bodies.
      • Weinstock L.B.
      • Shatz B.A.
      • Thyssen S.E.
      Esophageal food bolus obstruction: evaluation of extraction and modified push techniques in 75 cases.
      Several procedure-related variables have been associated with a higher overall risk of perforation in this population:
      • Increasing time between presentation and endoscopic management
        • Park J.H.
        • Park C.H.
        • Park J.H.
        • et al.
        Review of 209 cases of foreign bodies in the upper gastrointestinal tract and clinical factors for successful endoscopic removal.
        ,
        • Sung S.H.
        • Jeon S.W.
        • Son H.S.
        • et al.
        Factors predictive of risk for complications in patients with oesophageal foreign bodies.
        : Although the optimal timing for performing EGD on these patients has not been well established, EGD within 24 hours of presentation should be considered when the site of the bolus is suspected to be esophageal.
      • Larger (≥3 cm) foreign body size.
        • Sung S.H.
        • Jeon S.W.
        • Son H.S.
        • et al.
        Factors predictive of risk for complications in patients with oesophageal foreign bodies.
      • Presence of an ingested bone.
        • Sung S.H.
        • Jeon S.W.
        • Son H.S.
        • et al.
        Factors predictive of risk for complications in patients with oesophageal foreign bodies.
      • Use of an endoscopic instrument to retrieve or extract a bolus
        • Cha M.H.
        • Sandooja R.
        • Khalid S.
        • et al.
        Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
        : however, other studies demonstrate the equivalence of instrument-assisted techniques to the push technique as described above, and selection bias may play a role in interpreting these data
        • Schupack D.A.
        • Lenz C.J.
        • Geno D.M.
        • et al.
        The evolution of treatment and complications of esophageal food impaction.
        ,
        • Weinstock L.B.
        • Shatz B.A.
        • Thyssen S.E.
        Esophageal food bolus obstruction: evaluation of extraction and modified push techniques in 75 cases.
        ; hence, an optimal strategy is not well established.
      • Use of an overtube can very rarely cause perforation at the level of the hypopharynx, cricopharyngeus, or esophagus.
        • Inoki K.
        • Konda K.
        • Katagiri A.
        • et al.
        Successful management of pharyngeal perforation caused by overtube insertion during endoscopic submucosal dissection.
        ,
        • Wells C.D.
        • Fleischer D.E.
        Overtubes in gastrointestinal endoscopy.

      Infection

      Aspiration pneumonia is the most common infectious AE related to EGD performed for management of a foreign body or impaction. In a retrospective cohort of 173 patients, the combined incidence of immediate and delayed aspiration pneumonia was over 6% (4.6% immediate, 1.7% delayed).
      • Sengupta N.
      • Tapper E.B.
      • Corban C.
      • et al.
      The clinical predictors of aetiology and complications among 173 patients presenting to the emergency department with oesophageal food bolus impaction from 2004-2014.
      In a large retrospective series of over 900 patients, the incidence of delayed aspiration pneumonia was 1.8%.
      • Cha M.H.
      • Sandooja R.
      • Khalid S.
      • et al.
      Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: a large single-center retrospective review.
      In a separate multicenter study of 214 patients, the risk was shown to be similar, at 3%.
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      However, it should be noted that in this study, 24% of patients underwent endotracheal intubation before the EGD, which has been associated with a greater risk of pneumonia in a meta-analysis considering emergent EGD for other indications.
      • Chaudhuri D.
      • Bishay K.
      • Tandon P.
      • et al.
      Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: a systematic review and meta-analysis.
      Although endotracheal intubation is often performed before EGD to prevent aspiration in this patient population, the effectiveness of this practice in reducing rates of aspiration pneumonia has not yet been well characterized.

      Cardiopulmonary AEs

      Cardiovascular and respiratory AEs occurred in 1.5% and 2.9%, respectively, of 200 patients undergoing EGD for foreign body impaction
      • Andrade C.M.
      • Patel B.
      • Vellanki M.
      • et al.
      Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea.
      ; however, it is unclear what proportion of patients received endotracheal intubation. In a retrospective series from 2011 to 2014 where endotracheal intubation was performed before EGD in 24% of cases, cardiopulmonary AEs occurred in 4.4% of patients who are believed to be sicker patients requiring intubation.
      • Melendez-Rosado J.
      • Corral J.E.
      • Patel S.
      • et al.
      Esophageal food impaction: causes, elective intubation, and associated adverse events.
      This is the only study that reported the rate of intubation, and it suggests that intubation may not be a prerequisite in this patient population. European guidelines recommend intubation in uncooperative patients or those at high risk of aspiration, such as proximal esophageal locations of a foreign body, food bolus impaction, and a known full stomach.
      • Birk M.
      • Bauerfeind P.
      • Deprez P.H.
      • et al.
      Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
      However, given the paucity of available evidence describing AEs in this population and their predictors, the impact of endotracheal intubation on the incidence of cardiopulmonary AEs in patients undergoing EGD for foreign body impaction is uncertain.

      EGD with Dilation

      Dilation during EGD has become more common over time, likely because of the increasing prevalence of GERD, EoE, and endoscopic bariatric surgeries that can result in stenosis and stricture formation.
      • Peery A.F.
      • Crockett S.D.
      • Murphy C.C.
      • et al.
      Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021.
      ,
      • Arias A.
      • Perez-Martinez I.
      • Tenias J.M.
      • et al.
      Systematic review with meta-analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies.
      • Dellon E.S.
      Epidemiology of eosinophilic esophagitis.
      • Baumann A.J.
      • Mramba L.K.
      • Hawkins R.B.
      • et al.
      Endoscopic dilation of bariatric RNY anastomotic strictures: a systematic review and meta-analysis.
      • Brunaldi V.O.
      • Galvao Neto M.
      • Zundel N.
      • et al.
      Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment.

      Bleeding

      Esophageal dilation

      The true rate of bleeding after EGD with esophageal dilation is difficult to accurately assess given important differences in definitions and methods of ascertainment of this outcome between studies but overall is very low. In a large, recent, claims-based study of over 160,000 EGDs with esophageal dilation, clinically significant bleeding, defined according to the International Classification of Diseases codes, occurred in .07% of patients.
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      For comparison, a meta-analysis of randomized trials that included 461 patients reported an overall bleeding rate of .7%,
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      confirming that study methodology is likely a factor in determining bleeding rates. Factors associated with higher bleeding risk after esophageal dilation include male sex, Barrett’s esophagus, and esophageal malignancy.
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      The choice of dilator (balloon vs bougie) has not been shown to predict the risk of bleeding in patients undergoing dilation of benign esophageal strictures.
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      Studies assessing esophageal dilation in patients with EoE have reported similar rates of bleeding to those without EoE. In 2 separate meta-analyses assessing outcomes of esophageal dilations in adults and children with EoE, bleeding occurred after .03% and .05% of procedures.
      • Dougherty M.
      • Runge T.M.
      • Eluri S.
      • et al.
      Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis.
      ,
      • Moawad F.J.
      • Molina-Infante J.
      • Lucendo A.J.
      • et al.
      Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.

      Gastroduodenal dilation

      Balloon dilation of benign gastroduodenal strictures because of inflammatory conditions such as Crohn’s disease or peptic ulcer disease is also routinely performed. In a single-center analysis of 264 patients treated with dilation for benign gastric outlet obstruction, self-limited bleeding occurred in 7.7% of patients, but none of these events was deemed clinically significant because they did not lead to increased hospitalizations or requirements for blood transfusion.
      • Kochhar R.
      • Malik S.
      • Gupta P.
      • et al.
      Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.
      Similarly, in a study of 89 balloon dilations of the pylorus in patients with delayed gastric emptying after esophagectomy, no clinically significant episodes of bleeding were reported.
      • Maus M.K.
      • Leers J.
      • Herbold T.
      • et al.
      Gastric outlet obstruction after esophagectomy: retrospective analysis of the effectiveness and safety of postoperative endoscopic pyloric dilatation.
      A meta-analysis of 141 EGDs with balloon dilation of gastroduodenal strictures in the setting of Crohn’s disease reported a 2.1% bleeding rate.
      • Bettenworth D.
      • Mücke M.M.
      • Lopez R.
      • et al.
      Efficacy of endoscopic dilation of gastroduodenal Crohn's disease strictures: a systematic review and meta-analysis of individual patient data.
      Self-limited bleeding has been shown to occur more commonly in patients undergoing dilation for caustic strictures compared with peptic strictures (13.1% vs 2.8%).
      • Kochhar R.
      • Malik S.
      • Gupta P.
      • et al.
      Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.

      Postsurgical stricture dilation

      Endoscopic dilation is an established therapy in the management of anastomotic strictures after bariatric or other surgery. A meta-analysis of 21 studies including 896 patients undergoing dilation for post Roux-en-Y gastrojejunostomy anastomotic strictures demonstrated a very low overall bleeding rate of .1%.
      • Baumann A.J.
      • Mramba L.K.
      • Hawkins R.B.
      • et al.
      Endoscopic dilation of bariatric RNY anastomotic strictures: a systematic review and meta-analysis.
      In a 2020 meta-analysis including 18 studies of 426 patients undergoing endoscopic balloon dilation of gastric stenosis after sleeve gastrectomy, the clinically significant bleeding rate was .5%.
      • Chang S.H.
      • Popov V.B.
      • Thompson C.C.
      Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis.
      The presence of a presumed ischemic segment has been shown to predict higher rates of bleeding.
      • de Moura E.G.H.
      • Orso I.R.B.
      • Aurélio E.F.
      • et al.
      Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery.

      Perforation

      Esophageal dilation

      The overall rate of esophageal perforation after dilation ranges from .09% to .7%.
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      ,
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      In a nationwide study of over 160,000 esophageal dilations, perforation occurred in .09% of patients.
      • Mullen M.B.
      • Witt M.A.
      • Stromberg A.J.
      • et al.
      National database outcomes of esophageal dilations.
      A meta-analysis of 5 randomized controlled trials including 461 patients undergoing endoscopic dilation of benign esophageal strictures demonstrated a perforation rate of .7%, demonstrating a 10-fold difference in the rate of this outcome depending on the study methodology used.
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      In a study identifying over 169,000 esophageal stricture dilations using the National Inpatient Sample database of hospital discharges, perforation occurred at a rate of .5%.
      • Goyal A.
      • Chatterjee K.
      • Yadlapati S.
      • et al.
      Health-care utilization and complications of endoscopic esophageal dilation in a national population.
      A separate single-center retrospective analysis of over 2000 bougie and balloon dilations reported a perforation rate of .5%.
      • Grooteman K.V.
      • Wong Kee Song L.M.
      • Vleggaar F.P.
      • et al.
      Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.
      Potential risk factors for perforation are as follows:
      • Male sex.
        • Mullen M.B.
        • Witt M.A.
        • Stromberg A.J.
        • et al.
        National database outcomes of esophageal dilations.
      • Age ≥70 years,
        • Mullen M.B.
        • Witt M.A.
        • Stromberg A.J.
        • et al.
        National database outcomes of esophageal dilations.
        although the associations of both age and sex could be confounded by disease status.
      • Distal esophageal location and smaller initial stricture diameter under 10 mm, which have been inconsistently associated with a higher risk of perforation.
        • Grooteman K.V.
        • Wong Kee Song L.M.
        • Vleggaar F.P.
        • et al.
        Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.
        ,
        • Hagel A.F.
        • Naegel A.
        • Dauth W.
        • et al.
        Perforation during esophageal dilatation: a 10-year experience.
      • Dilation of malignant strictures, which portends a higher risk of perforation compared with benign strictures (.9% vs .5%).
        • Goyal A.
        • Chatterjee K.
        • Yadlapati S.
        • et al.
        Health-care utilization and complications of endoscopic esophageal dilation in a national population.
        Furthermore, patients experiencing this outcome also experience higher rates of in-hospital mortality (3.1% vs 1.4%).
        • Goyal A.
        • Chatterjee K.
        • Yadlapati S.
        • et al.
        Health-care utilization and complications of endoscopic esophageal dilation in a national population.
      • Presence of head and neck cancer.
        • Moss W.J.
        • Pang J.
        • Orosco R.K.
        • et al.
        Esophageal dilation in head and neck cancer patients: a systematic review and meta-analysis.
      • Dilation of strictures caused by corrosive injury, which may be associated with a greater risk of perforation based on limited evidence (5.6%-36.4%).
        • Chiu Y.C.
        • Liang C.M.
        • Tam W.
        • et al.
        The effects of endoscopic-guided balloon dilations in esophageal and gastric strictures caused by corrosive injuries.
      • Pneumatic dilation for achalasia, which has been associated with a higher perforation risk of 2% to 5%,
        • van Hoeij F.B.
        • Prins L.I.
        • Smout A.
        • et al.
        Efficacy and safety of pneumatic dilation in achalasia: a systematic review and meta-analysis.
        • Bonifácio P.
        • de Moura D.T.H.
        • Bernardo W.M.
        • et al.
        Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials.
        • Ghoshal U.C.
        • Karyampudi A.
        • Verma A.
        • et al.
        Perforation following pneumatic dilation of achalasia cardia in a university hospital in northern India: a two-decade experience.
        • Katzka D.A.
        • Castell D.O.
        An analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia [Review].
        with this risk being more common at the initial dilation session and when using a 35-mm versus 30-mm balloon.
        • van Hoeij F.B.
        • Prins L.I.
        • Smout A.
        • et al.
        Efficacy and safety of pneumatic dilation in achalasia: a systematic review and meta-analysis.
      In contrast, no clear associations have been elucidated between dilator size, compliance with the “rule of 3” (using a maximum of 3 dilator sizes, including the starting dilator, in a single session),
      • Grooteman K.V.
      • Wong Kee Song L.M.
      • Vleggaar F.P.
      • et al.
      Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.
      or dilator type (balloon vs bougie).
      • Josino I.R.
      • Madruga-Neto A.C.
      • Ribeiro I.B.
      • et al.
      Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis.
      Similarly, pooled perforation rates in patients with EoE undergoing esophageal dilation range between .4% and .9% in several meta-analyses, indicating no significantly increased risk in this population compared with those without EoE.
      • Dougherty M.
      • Runge T.M.
      • Eluri S.
      • et al.
      Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis.
      ,
      • Moawad F.J.
      • Molina-Infante J.
      • Lucendo A.J.
      • et al.
      Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.
      ,
      • Moole H.
      • Jacob K.
      • Duvvuri A.
      • et al.
      Role of endoscopic esophageal dilation in managing eosinophilic esophagitis: a systematic review and meta-analysis.

      Gastroduodenal dilation

      In a meta-analysis of 11 studies of EGD with balloon dilation of gastroduodenal strictures in the setting of Crohn’s disease, a perforation risk of 1.5% was reported.
      • Bettenworth D.
      • Mücke M.M.
      • Lopez R.
      • et al.
      Efficacy of endoscopic dilation of gastroduodenal Crohn's disease strictures: a systematic review and meta-analysis of individual patient data.
      In a review of 111 patients who underwent endoscopic balloon dilation of caustic injury–induced gastric outlet obstruction, perforation occurred in 1.8% of patients.
      • Kochhar R.
      • Malik S.
      • Reddy Y.R.
      • et al.
      Endoscopic balloon dilatation is an effective management strategy for caustic-induced gastric outlet obstruction: a 15-year single center experience.

      Postsurgical stricture dilation

      A meta-analysis of 21 studies including 896 patients undergoing endoscopic dilation for gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass surgery reported a perforation rate of 2.3%, but only .9% required surgical intervention.
      • Baumann A.J.
      • Mramba L.K.
      • Hawkins R.B.
      • et al.
      Endoscopic dilation of bariatric RNY anastomotic strictures: a systematic review and meta-analysis.
      The presence of an ischemic segment or a fistula has been associated with a higher risk of perforation.
      • de Moura E.G.H.
      • Orso I.R.B.
      • Aurélio E.F.
      • et al.
      Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery.
      In a meta-analysis of 18 studies of 426 patients undergoing endoscopic balloon dilation of gastric stenosis complicating sleeve gastrectomy, the overall perforation rate was .5%.
      • Chang S.H.
      • Popov V.B.
      • Thompson C.C.
      Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis.

      EGD with Stent Placement

      Bleeding

      Esophageal stent placement

      Palliative stent placement for advanced esophageal malignancy has been shown to have a relatively higher risk of bleeding. In a multicenter cohort study of self-expanding metal stent (SEMS) insertion for inoperable malignant esophageal strictures, bleeding occurred in 3.7% of patients.
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      In a separate study of 442 patients who underwent SEMS placement for similar indications, bleeding occurred in 1.3% of patients.
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      In a 2020 meta-analysis of 231 patients that compared fully covered to partially covered SEMS insertion for palliation in esophageal cancer, the bleeding risk was the same for both stent types.
      • Wang C.
      • Wei H.
      • Li Y.
      Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis.
      In a meta-analysis including 444 patients with stents placed for benign indications, the risk of bleeding was 1.8%.
      • Fuccio L.
      • Hassan C.
      • Frazzoni L.
      • et al.
      Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.

      Gastroduodenal stent placement

      Malignant gastric outlet obstruction has historically been managed with endoscopic SEMS placement.
      • Forbes N.
      • Coelho-Prabhu N.
      • Al-Haddad M.A.
      • et al.
      ASGE Standards of Practice Committee
      Adverse events associated with EUS and EUS-guided procedures.
      ,
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.
      A meta-analysis of 19 studies including 1281 patients undergoing SEMS placement for malignant gastric outlet obstruction reported an overall bleeding rate of 4.1%, with clinically significant bleeding requiring intervention occurring in .8% of patients.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      Similarly, in a multicenter study of 202 patients having received duodenal stent placement for malignant gastroduodenal obstruction, bleeding occurred in 3% of patients, although half of these episodes were self-limited.
      • Costamagna G.
      • Tringali A.
      • Spicak J.
      • et al.
      Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: an international prospective multicentre registry.
      Bleeding appears to be more common in patients treated with partially covered stents.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.

      Perforation

      Esophageal stent placement

      In a recent meta-analysis of palliative esophageal stent placement without fluoroscopy in 1778 patients from 17 studies, the pooled perforation rate was 1.2%, indicating the safety of this approach.
      • Chandan S.
      • Mohan B.P.
      • Khan S.R.
      • et al.
      Clinical efficacy and safety of palliative esophageal stenting without fluoroscopy: a systematic review and meta-analysis.
      In the same study, retrosternal chest pain was found to be the most common AE reported (10.4%). In a retrospective review of 442 patients undergoing SEMS placement for dysphagia because of unresectable esophageal cancer, perforation occurred in .9% of patients.
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      This rate is similar to that reported in a separate multicenter cohort study of SEMS placement for malignant esophageal stricture (1.2%).
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      In the meta-analysis of 444 patients receiving esophageal stent placement for benign indications, chest pain was reported in 6.5% and perforation in 4.4%.
      • Fuccio L.
      • Hassan C.
      • Frazzoni L.
      • et al.
      Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.
      In a meta-analysis comparing esophageal stents with other therapies for inoperable malignant strictures, a tracheoesophageal fistula was reported in 4.5% to 5.6% patients in 2 cohorts.
      • Lai A.
      • Lipka S.
      • Kumar A.
      • et al.
      Role of esophageal metal stents placement and combination therapy in inoperable esophageal carcinoma: a systematic review and meta-analysis.

      Gastroduodenal stent placement

      Pooled data from the recent ASGE guideline reviewing the role of endoscopy in management of gastroduodenal obstruction including covered and uncovered stents show a perforation rate of 13 in 944 (1.3%).
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.
      In a retrospective review of 219 patients undergoing SEMS placement for gastroduodenal outlet obstruction, perforation occurred in 1.4% of patients.
      • Ratone J.P.
      • Caillol F.
      • Zemmour C.
      • et al.
      Outcomes of duodenal stenting: experience in a French tertiary center with 220 cases.
      In a meta-analysis of 19 studies including 1281 patients undergoing SEMS placement for malignant gastric outlet obstruction, perforation occurred in 1.2% of patients.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      The rate of perforation after stent placement of gastroduodenal stenosis is comparable between partially covered and uncovered metal stents.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.

      Stent migration

      When placing an indwelling luminal stent, an additional consideration for endoscopists and patients is the risk of stent migration. This AE can occur with variable frequency depending on both the indication for the procedure and the location of the stent. In cases of SEMS placement for benign esophageal strictures, fistulae, and leaks, the rate of stent migration has been reported at 40% to 50% in multiple single-center studies assessing both fully and partially covered SEMSs.
      • Suzuki T.
      • Siddiqui A.
      • Taylor L.J.
      • et al.
      Clinical outcomes, efficacy, and adverse events in patients undergoing esophageal stent placement for benign indications: a large multicenter study.
      ,
      • Dan D.T.
      • Gannavarapu B.
      • Lee J.G.
      • et al.
      Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES).
      An overall migration rate of 28.6% was reported in a meta-analysis of 444 patients treated with esophageal stents for benign indications.
      • Fuccio L.
      • Hassan C.
      • Frazzoni L.
      • et al.
      Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.
      Conversely, when placed for the management of malignant esophageal strictures, the risk of partially covered and fully covered SEMS migration was considerably lower, ranging from 4.1% in a large retrospective study
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      to 12.2% in a multicenter prospective study.
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      In the case of SEMS placement for malignant gastric outlet obstruction, the pooled risk of migration was reported at 4.3% in a meta-analysis of over 1200 patients.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      The risk of stent migration out of the esophagus can be mitigated through-the-scope or over-the-scope through various anchoring techniques.
      • Wang C.
      • Lou C.
      Randomized controlled trial to investigate the effect of metal clips on early migration during stent implantation for malignant esophageal stricture.
      ,
      • Vanbiervliet G.
      • Filippi J.
      • Karimdjee B.S.
      • et al.
      The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study.
      Chief among these is fixation with endoscopic suturing; in a meta-analysis of 212 patients undergoing suturing of SEMSs placed for several indications including strictures, leaks, and fistulae, the migration rate was reported to be 15.9%.
      • Law R.
      • Prabhu A.
      • Fujii-Lau L.
      • et al.
      Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis.
      Importantly, in the setting of malignant esophageal strictures, the risk of migration was demonstrated to be no different between fully covered and partially covered metal stents in a 2020 meta-analysis including over 200 patients.
      • Wang C.
      • Wei H.
      • Li Y.
      Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis.
      The risk of stent migration in the case of malignant gastric outlet obstruction has been demonstrated to be higher when partially covered (vs uncovered) stents are deployed.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.

      Stent occlusion

      The risk of stent occlusion similarly depends on the indication for the procedure, design of the stent, and location of the stent. Occlusion is possible both because of tissue ingrowth of an uncovered metal stent and from occlusion by ingested food. When performed for the management of malignant esophageal strictures, SEMS insertion was complicated by tissue overgrowth and by food impaction in 8.5% and 2.4% of patients, respectively, in a multicenter prospective study.
      • Repici A.
      • Jovani M.
      • Hassan C.
      • et al.
      Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study.
      This was similar to a reported risk of tissue overgrowth of 12.4% in a large retrospective study of over 400 patients undergoing stent placement for the same indication.
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      In the case of SEMS placement for malignant gastric outlet obstruction, the pooled risk of occlusion was reported at 12.6% in a meta-analysis of over 1200 patients.
      • van Halsema E.E.
      • Rauws E.A.
      • Fockens P.
      • et al.
      Self-expandable metal stents for malignant gastric outlet obstruction: a pooled analysis of prospective literature.
      This was confirmed in the recent ASGE guideline on management of gastroduodenal obstruction that found occlusion of 4.1% with covered SEMSs versus 25.2% with uncovered SEMSs.
      • Jue T.L.
      • Storm A.C.
      • Naveen M.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.

      Infection

      Infectious AEs of EGD with stent placement mostly relate to aspiration. In a single-center retrospective review of 442 patients undergoing SEMS placement for dysphagia because of esophageal cancer, pneumonia occurred in 2.5% of patients.
      • Włodarczyk J.R.
      • Kużdżał J.
      Stenting in palliation of unresectable esophageal cancer.
      In a review of 219 patients undergoing SEMS placement for malignant gastric outlet obstruction, pneumonia occurred in .5% of patients.
      • Ratone J.P.
      • Caillol F.
      • Zemmour C.
      • et al.
      Outcomes of duodenal stenting: experience in a French tertiary center with 220 cases.

      EGD with Hemostasis or Prophylaxis of Bleeding

      Summary of AEs

      Hemostasis for active nonvariceal upper GI bleeding

      AEs associated with hemostasis of nonvariceal bleeding are heterogeneously defined and inconsistently reported in the literature and are therefore difficult to categorize and synthesize. A network meta-analysis of endoscopic therapies for high-risk bleeding peptic ulcers demonstrated that both epinephrine plus mechanical therapy and epinephrine plus thermal therapy demonstrated better AE profiles compared with epinephrine monotherapy or sclerosant injection, while significantly decreasing the odds of rebleeding (OR, .19 [95% CI, .07-.52] and .30 [95% CI, .10-.91], respectively).
      • Shi K.
      • Shen Z.
      • Zhu G.
      • et al.
      Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers.
      AEs from this overall group of treatments (injection, mechanical modalities, thermal modalities) include low risks of bleeding and perforation.
      • Shi K.
      • Shen Z.
      • Zhu G.
      • et al.
      Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers.
      ,
      • Pescatore P.
      • Jornod P.
      • Borovicka J.
      • et al.
      Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial.
      The use of monopolar hemostatic forceps with soft coagulation, a relatively newer approach in the treatment of active peptic ulcer bleeding, appears to have a similar AE rate compared with the traditional therapies listed above from a 2020 meta-analysis including 6 studies.
      • Kamal F.
      • Khan M.A.
      • Tariq R.
      • et al.
      Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding.
      The rate of AEs directly associated with the use of TC-325 hemostatic powder, more commonly known as Hemospray (Cook Medical, Winston-Salem, NC, USA), in the management of nonmalignant upper GI bleeding was reported to be .7% in a large meta-analysis of over 1900 patients,
      • Chahal D.
      • Sidhu H.
      • Zhao B.
      • et al.
      Efficacy of Hemospray (TC-325) in the treatment of gastrointestinal bleeding: an updated systematic review and meta-analysis.
      including self-limited abdominal pain. Similarly, low AE rates have been associated with its use in upper GI bleeding from GI malignant etiologies.
      • Chen Y.I.
      • Wyse J.
      • Lu Y.
      • et al.
      TC-325 hemostatic powder versus current standard of care in managing malignant GI bleeding: a pilot randomized clinical trial.
      Over-the-scope clip devices are another tool for the management of active nonvariceal bleeding. In a meta-analysis of 769 patients, only .3% experienced AEs.
      • Zhong C.
      • Tan S.
      • Ren Y.
      • et al.
      Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis.
      In another review of 1519 procedures using over-the-scope clips, overall over-the-scope clip–related AEs were reported in 1.7% of patients, with .6% of these requiring surgical intervention.
      • Kobara H.
      • Mori H.
      • Nishiyama N.
      • et al.
      Over-the-scope clip system: a review of 1517 cases over 9 years.
      These AEs included luminal obstruction and clip maldeployment.

      Hemostasis of active variceal bleeding

      AEs associated with hemostasis of variceal bleeding are similarly difficult to synthesize given heterogeneous definitions and inconsistent reporting. The rate of intraprocedural bleeding with injection of glue into gastric varices was reported to be 1.4% in a large, single-center, retrospective analysis of 628 procedures.
      • Guo Y.W.
      • Miao H.B.
      • Wen Z.F.
      • et al.
      Procedure-related complications in gastric variceal obturation with tissue glue.
      Fever is a common AE after cyanoacrylate injection, occurring in 35.0% of patients,
      • Ríos Castellanos E.
      • Seron P.
      • Gisbert J.P.
      • et al.
      Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension.
      and subjective chest pain and dysphagia are also potential AEs.
      • El Amin H.
      • Abdel Baky L.
      • Sayed Z.
      • et al.
      A randomized trial of endoscopic variceal ligation versus cyanoacrylate injection for treatment of bleeding junctional varices.
      Infectious AEs are rare but possible with either approach,
      • Tan P.C.
      • Hou M.C.
      • Lin H.C.
      • et al.
      A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation.
      but it is difficult to attribute these to endoscopic interventions as opposed to severe underlying medical comorbidities of some patients (eg, in cases of spontaneous bacterial peritonitis or sepsis). In a meta-analysis of 23 studies involving balloon tamponade (570 patients) or esophageal stenting (188 patients) as bridge therapies to temporize refractory variceal bleeding, the overall major AE rate for balloon tamponade was 20.4%, whereas there was a high risk of migration of 23.8% with the stenting approach.
      • Rodrigues S.G.
      • Cárdenas A.
      • Escorsell À.
      • et al.
      Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis.
      In the same meta-analysis, balloon tamponade for active variceal bleeding was shown to result in bronchopulmonary aspiration and pneumonia in 11.2% of cases.
      • Rodrigues S.G.
      • Cárdenas A.
      • Escorsell À.
      • et al.
      Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis.
      A meta-analysis of 14 randomized studies and 1236 patients with active esophageal variceal bleeding comparing endoscopic variceal ligation and endoscopic sclerotherapy found a lower rate of AEs in the ligation group (relative risk [RR], .28; 95% CI, .13-.58).
      • Dai C.
      • Liu W.X.
      • Jiang M.
      • et al.
      Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis.

      Prophylaxis or treatment of nonbleeding nonvariceal lesions

      A systematic review and meta-analysis of 24 studies comparing effectiveness and safety of radiofrequency ablation and argon plasma coagulation in the treatment of gastric antral vascular ectasia revealed that radiofrequency ablation resulted in significantly fewer and less severe AEs as compared with argon plasma coagulation (1.9% vs 5.1%, respectively).
      • McCarty T.R.
      • Rustagi T.
      Comparative effectiveness and safety of radiofrequency ablation versus argon plasma coagulation for treatment of gastric antral vascular ectasia: a systematic review and meta-analysis.
      These most commonly consisted of bleeding ulcers that developed after therapy.
      • McCarty T.R.
      • Rustagi T.
      Comparative effectiveness and safety of radiofrequency ablation versus argon plasma coagulation for treatment of gastric antral vascular ectasia: a systematic review and meta-analysis.
      A meta-analysis of 11 studies assessing endoscopic band ligation for gastric antral vascular ectasia showed that AEs occurred after 10.9% of procedures, with a rebleeding rate of 9.0%.
      • McCarty T.R.
      • Hathorn K.E.
      • Chan W.W.
      • et al.
      Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis.
      AEs included postbanding bleeding ulcers, fever, and subjective abdominal pain.
      • Elhendawy M.
      • Mosaad S.
      • Alkhalawany W.
      • et al.
      Randomized controlled study of endoscopic band ligation and argon plasma coagulation in the treatment of gastric antral and fundal vascular ectasia.

      Prophylaxis of nonbleeding varices

      A 2019 Cochrane review of studies assessing endoscopic band ligation in the prophylaxis of esophageal variceal bleeding reported a low overall rate of AEs related to this procedure, including dysphagia in 6% to 22% of patients, chest pain in 8% to 23% of patients, self-limited fever in 3% to 11% of patients, and retrosternal burning in up to 40% of patients.
      • Vadera S.
      • Yong C.W.K.
      • Gluud L.L.
      • et al.
      Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices.
      The endoscopic injection of cyanoacrylate or other glue into gastric varices has resulted in distant embolic events according to multiple case reports.
      • Kim J.
      • Chun H.J.
      • Hyun J.J.
      • et al.
      Splenic infarction after cyanoacrylate injection for fundal varices.
      ,
      • Kok K.
      • Bond R.P.
      • Duncan I.C.
      • et al.
      Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature.
      Performing glue injection, with or without concomitant coiling, under EUS guidance may help mitigate these risks but is not a prerequisite.
      • Forbes N.
      • Coelho-Prabhu N.
      • Al-Haddad M.A.
      • et al.
      ASGE Standards of Practice Committee
      Adverse events associated with EUS and EUS-guided procedures.

      EGD with Gastrostomy or Jejunostomy Tube Placement

      Bleeding

      Clinically significant bleeding after PEG tube placement has been reported to occur in between .6% and 1.2% of cases
      • McClave S.A.
      • Chang W.K.
      Complications of enteral access.
      and is of variable clinical significance, almost always minor and self-limited in nature. A 2020 meta-analysis of 320 PEG patients demonstrated a .9% rate of minor bleeding associated with PEG tube insertion.
      • Yuan T.W.
      • He Y.
      • Wang S.B.
      • et al.
      Technical success rate and safety of radiologically inserted gastrostomy versus percutaneous endoscopic gastrostomy in motor neuron disease patients undergoing: a systematic review and meta-analysis.
      Similar rates of bleeding have been reported for percutaneous endoscopic jejunostomy (PEJ) procedures, with a reported rate of 2.4% in a single-center 10-year cohort of 83 patients
      • Lim A.H.
      • Schoeman M.N.
      • Nguyen N.Q.
      Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort.
      and no bleeding events in a separate series of 59 cases.
      • Strong A.T.
      • Sharma G.
      • Davis M.
      • et al.
      Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement: a single institution experience and outcomes to 30 days and beyond.
      A meta-analysis of 11 studies including 6233 patients undergoing PEG tube placement while on antiplatelet therapy reported a bleeding rate of 2.67%.
      • Lucendo A.J.
      • Sánchez-Casanueva T.
      • Redondo O.
      • et al.
      Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis.
      Conversely, a large retrospective analysis of 1613 consecutive PEG tube placements, of which 95.5% of patients received some form of uninterrupted periprocedural antithrombotic therapy, the rate of bleeding requiring transfusion or intervention was .39%,
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.
      suggesting that bleeding risk is likely similar to patients on no antithrombotic therapy. The ASGE guideline on the management of antithrombotic agents for endoscopy describes both PEG and PEJ as high-risk procedures overall and recognizes that aspirin alone does not portend an increased risk of bleeding.
      • Johnson B.
      • Basson M.D.
      Absence of complications after endoscopic mucosal biopsy.
      Risk factors associated with a higher risk of bleeding after PEG placement are as follows:
      • Active dual antiplatelet therapy or full anticoagulation.
        • Johnson B.
        • Basson M.D.
        Absence of complications after endoscopic mucosal biopsy.
      • Obesity: In a single-center analysis of 67 obese patients who underwent PEG placement, hemoperitoneum occurred in 3.4% of cases, with patient weight of >250 pounds being shown to predict the overall risk of AEs with an OR of 3.86 (95% CI, 1.02-14.57).
        • Wiggins T.F.
        • Garrow D.A.
        • DeLegge M.H.
        Evaluation of percutaneous endoscopic feeding tube placement in obese patients.
      • Diabetes mellitus.
        • Lee C.
        • Im J.P.
        • Kim J.W.
        • et al.
        Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      It is also noteworthy that the insertion of PEG tubes is associated with a lower risk of bleeding compared with insertion of gastrostomy tubes using interventional radiology techniques. A study of over 184,000 patients undergoing gastrostomy tube placement showed an increased risk of bleeding with interventional radiology–placed PEG tubes (OR, 1.84; 95% CI, 1.26-2.68; P = .002) compared with endoscopically placed tubes.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      In a nationwide sample of over 33,000 patients, interventional radiology–placed PEG tubes had a higher risk of bleeding (OR, 1.47; 95% CI, 1.18-1.83; P < .01).
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Comparative safety of endoscopic vs radiological gastrostomy tube placement: outcomes from a large, nationwide Veterans Affairs database.

      Perforation

      In a recent series of 1613 patients undergoing PEG placement, uncontained gastric perforation was reported in .2% of patients, resulting in sepsis and subsequent mortality in all.
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.
      Similarly, in a multicenter retrospective study of 1625 patients, peritonitis occurred in .8% of patients.
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      Perforation of the transverse colon is another major potential AE. This was reported in .2% in the large inpatient cohort and in .12% in a nationwide cohort.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      ,
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Comparative safety of endoscopic vs radiological gastrostomy tube placement: outcomes from a large, nationwide Veterans Affairs database.
      There was a higher risk for interventional radiology–guided PEG placement versus endoscopic PEG (OR, 1.90; 95% CI, 1.26-2.86).
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      Although evidence is scarce, PEJ procedures may carry a higher risk of perforation, with this event mostly observed at the time of traction tube removal and/or exchange.
      • Lim A.H.
      • Schoeman M.N.
      • Nguyen N.Q.
      Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort.
      ,
      • Hoyer R.J.
      • Arora A.S.
      • Baron T.H.
      Complications after traction removal of direct percutaneous endoscopic jejunostomy: three case reports.
      Transhepatic placement of PEG tubes is an exceedingly rare AE.
      • Chhaparia A.
      • Hammami M.B.
      • Bassuner J.
      • et al.
      Trans-hepatic percutaneous endoscopic gastrostomy tube placement: a case report of a rare complication and literature review.

      Infection

      Most infections related to PEG or PEJ tube placement are superficial site infections that commonly respond to short treatment courses with antibiotics. In a series of 1613 patients undergoing PEG tube placement, superficial site infection was reported in 2.1% of patients.
      • Thosani N.
      • Rashtak S.
      • Kannadath B.S.
      • et al.
      Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement.
      It was reported as .9% in a large inpatient cohort.
      • Kohli D.R.
      • Kennedy K.F.
      • Desai M.
      • et al.
      Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.
      In a multicenter study of 1625 patients, the most common infectious AEs were fever without evident infection in 3.5% of patients, peristomal infection in 3.4% of patients, and aspiration pneumonia in 1.5% of patients.
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      In this study, multivariable logistic regression demonstrated that the administration of periprocedural prophylactic antibiotics was associated with a reduction in the incidence of fever (OR, .58; 95% CI, .38-.88).
      • Lee C.
      • Im J.P.
      • Kim J.W.
      • et al.
      Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.
      In a single-center series of 59 cases of direct PEJ tube placement, 3.4% of patients experienced infectious AEs, including 1.7% of patients with aspiration pneumonia and 1.7% of patients with exit site infections.
      • Strong A.T.
      • Sharma G.
      • Davis M.
      • et al.
      Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement: a single institution experience and outcomes to 30 days and beyond.
      Obese patients are at a higher risk of cellulitis, with this AE occurring in 8.5% of patients with a body mass index of 30 kg/m2 or higher.
      • Wiggins T.F.
      • Garrow D.A.
      • DeLegge M.H.
      Evaluation of percutaneous endoscopic feeding tube placement in obese patients.
      The ASGE recommends antibiotic prophylaxis before both PEG and PEJ procedures.
      • Khashab M.A.
      • Chithadi K.V.
      • Acosta R.D.
      • et al.
      ASGE Standards of Practice Committee
      Antibiotic prophylaxis for GI endoscopy.
      Two systematic reviews showed a .32% to .56% risk of tumor seeding when the pull technique was used.
      • Rowell N.P.
      Tumor implantation following percutaneous endoscopic gastrostomy insertion for head and neck and oesophageal cancer: review of the literature.
      ,
      • Siu J.
      • Fuller K.
      • Nadler A.
      • et al.
      Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis.
      Hence, in this cohort, a direct push technique for placement is preferable when possible.

      Future Directions

      This document highlights several important areas within the field of EGD for which further high-quality research is needed to improve the strength of recommendations for future EGD-related guidelines. Below is a brief outline of these specific areas.
      • Predictors of AEs. Limited evidence is available regarding patient- and procedure-level predictors of AEs for routine EGD as well as more advanced EGD-guided techniques (Table 1). Dedicated efforts to reliably elucidate these independent predictors (ideally using prospective population-level cohort studies and clinical trials) are needed, especially for newer and/or evolving techniques and commonly used medications such as antithrombotic agents.
      • Data on AEs for novel EGD-guided procedures. More data, ideally in the form of randomized controlled trials and prospective observational studies, are needed to formally elucidate the AE rates and predictors of AEs for several novel EGD-guided procedures not described within this document, including Zenker’s diverticulectomy, antireflux endoscopy, and robotic-assisted endoscopy.
      • Implications for training. Data are scarce on both the learning curves and trainee-related AE profiles associated with most EGD-guided procedures described in this document. Data describing ideal procedural volumes and optimal training methods for these techniques as well as AEs associated with training are urgently needed.

      Conclusion

      Routine EGD with or without biopsy sampling is well established as a safe and effective procedure. Although several AEs are associated with routine EGD, their overall incidence is low. Additional interventional EGD-guided techniques are increasingly used as alternatives to surgical, radiologic, and other endoscopic approaches to managing GI disease and may be associated with higher AE rates compared with routine EGD. Endoscopists performing EGD-guided procedures should be aware of associated AE rates and their risk factors to optimize the informed consent process and patient selection.

      Disclosure

      The following authors disclosed financial relationships: N. Coelho-Prabhu is a consultant for Boston Scientific Corporation. N. Forbes is a consultant for Boston Scientific Corporation, Pentax of America, Inc, and Pendopharm Inc; is on the speaker bureau for Pentax of America, Inc and Boston Scientific Corporation; and has received research support from Pentax of America, Inc. N. Thosani is a consultant for and has received travel compensation and food and beverage from Boston Scientific Corporation; is a consultant and has received food and beverage from Covidien LP and Pentax of America, Inc; has been a speaker for AbbVie Inc; and has received food and beverage from Erbe USA, Inc and Ambu Inc. A. Storm is a consultant for and has received travel compensation from Apollo Endosurgery US Inc; is a consultant for GI Dynamics, Erbe, and Olympus Corporation of the Americas; is a consultant for and has received a research grant from Endo-TAGSS and Apollo Endosurgery; has received a research grant from Enterasense, Boston Scientific Corporation, and Endogenex; and has received food and beverage from Ambu Inc, Olympus Corporation of the Americas, Micro-tech Endoscopy USA, Inc, and Boston Scientific Corporation. D. Kohli has received a grant from Olympus Corporation of the Americas. L. Fujii-Lau has received food and beverage from Pfizer Inc and AbbVie Inc. S. Elhanafi has received travel compensation and food and beverage from Endogastric Solutions and Boston Scientific Corporation; has received food and beverage from Merit Medical Systems, Inc, Salix Pharmaceuticals, and Intercept Pharmaceuticals. J. Buxbaum is a consultant for and has received grant, travel compensation, and food and beverage compensation from Olympus America Inc; is a consultant for and received food and beverage compensation from Boston Scientific Corporation; is a consultant for Eagle Pharmaceuticals, Inc and Cook Medical LLC; has received grant compensation from Medtronic USA, Inc; and has received consulting fees from Gyrus ACMI, Inc and Wilson Cook Medical Incorporated. R. Kwon has received research support from AbbVie, Inc. S. Amateau is a consultant for and has received travel compensation and food and beverage from Olympus America Inc; is a consultant for and has received travel compensation from Cook Medical LLC; is a consultant for and has received food and beverage from Boston Scientific Corporation; and is a consultant for Endo-Therapeutics, Hemostasis LLC, Heraeus Medical Components, LLC, Merit Medical Systems Inc, Steris Corporation, and Taewoong Medical. M. Al-Haddad has received research support from Cook Endoscopy and Creatics, LLC; is a consultant for and has received teaching support from Boston Scientific Corporation. B. Qumseya has received food and beverage from Olympus America Inc. All other authors disclosed no financial relationships.

      Acknowledgments

      We acknowledge and are grateful for the contribution of Robyn Rosasco, who helped design and perform the electronic search strategies for this document, as well as Dr Jonathan Cohen, Dr Jenifer Lightdale, Dr Felix Leung, Dr Jean Chalhoub, Dr Madhav Desai, Dr Jorge Machicado, Dr Neil Marya, Dr Wenly Ruan, and Dr Sunil Sheth for their review of this document.
      This document was funded exclusively by the American Society for Gastrointestinal Endoscopy; no outside funding was received to support the development of this document.

      Appendix 1

      MEDLINE (OVID) search strategy

      Database: Ovid MEDLINE ALL
      Search Date: January 7, 2021
      Number of results: 4603
      • 1.
        exp endoscopy, digestive system/ and exp upper gastrointestinal tract/ 19,597
      • 2.
        (oesophagogastroduodenoscop∗ or esophagogastroduodenoscop∗ or gastroscop∗).tw,kf. 11,767
      • 3.
        (oesophageo-gastro-duodenoscop∗ or esophageo-gastro-duodenoscop∗ or gastro-scop∗).tw,kf. 4
      • 4.
        ((upper adj2 gastro∗) and endoscop∗).tw,kf. 11,747
      • 5.
        ((upper adj2 GI) and endoscop∗).tw,kf. 2390
      • 6.
        egd.tw,kf. 2391
      • 7.
        or/1-6 41,381
      • 8.
        ((adverse or dangerous or harmful or indirect or injurious or secondary or side or undesirable) adj1 (complication∗ or consequence∗ or effect∗ or event∗ or impact∗ or outcome∗ or reaction∗)).tw,kf. or exp “drug-related side effects and adverse reactions”/ or ae.fs. 2,325,892
      • 9.
        7 and 8 7199
      • 10.
        limit 9 to english language 6280
      • 11.
        (addresses or biography or case reports or comment or directory or editorial or festschrift or interview or lectures or legal cases or legislation or letter or news or newspaper article or patient education handout or popular works or congresses or consensus development conference or consensus development conference, nih or practice guideline).pt. not (exp animals/ not exp humans/) 4,179,901
      • 12.
        10 not 11 4603

      References

        • Early D.S.
        • Acosta R.D.
        • Chandrasekhara V.
        • et al.
        Adverse events associated with EUS and EUS with FNA.
        Gastrointest Endosc. 2013; 77: 839-843
        • Peery A.F.
        • Crockett S.D.
        • Murphy C.C.
        • et al.
        Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021.
        Gastroenterology. 2022; 162: 621-644
        • Ben-Menachem T.
        • Decker G.A.
        • Early D.S.
        • et al.
        Adverse events of upper GI endoscopy.
        Gastrointest Endosc. 2012; 76: 707-718
        • Evans J.A.
        • Early D.S.
        • Chandrasekhara V.
        • et al.
        • ASGE Standards of Practice Committee
        The role of endoscopy in the assessment and treatment of esophageal cancer.
        Gastrointest Endosc. 2013; 77: 328-334
        • Wani S.
        • Qumseya B.
        • Sultan S.
        • et al.
        • ASGE Standards of Practice Committee
        Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer.
        Gastrointest Endosc. 2018; 87: 907-931
        • Khashab M.A.
        • Vela M.F.
        • Thosani N.
        • et al.
        ASGE guideline on the management of achalasia.
        Gastrointest Endosc. 2020; 91: 213-227
        • Evans J.A.
        • Muthusamy V.R.
        • Acosta R.D.
        • et al.
        • American Society for Gastrointestinal Endoscopy Standards of Practice Committee
        The role of endoscopy in the bariatric surgery patient.
        Gastrointest Endosc. 2015; 81: 1063-1072
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Kim H.I.
        • Yoon J.Y.
        • Kwak M.S.
        • et al.
        Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database.
        Gut Liver. 2021; 15: 569-578
        • Montalvo R.D.
        • Lee M.
        Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy.
        Hepatogastroenterology. 1996; 43: 174-177
        • Yabe K.
        • Horiuchi A.
        • Kudo T.
        • et al.
        Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy.
        Dig Dis Sci. 2021; 66: 1548-1555
        • Fujita M.
        • Shiotani A.
        • Murao T.
        • et al.
        Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics.
        Dig Endosc. 2015; 27: 25-29
        • Bozkurt H.
        • Ölmez T.
        • Bulut C.
        • et al.
        The safety of upper gastrointestinal endoscopic biopsy in patients receiving antithrombic drugs. A single-centre prospective observational study.
        Prz Gastroenterol. 2020; 15: 234-240
        • Heublein V.
        • Pannach S.
        • Daschkow K.
        • et al.
        Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry.
        J Gastroenterol. 2018; 53: 236-246
        • Ara N.
        • Iijima K.
        • Maejima R.
        • et al.
        Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan.
        Dig Endosc. 2015; 27: 458-464
        • Acosta R.D.
        • Abraham N.S.
        • Chandrasekhara V.
        • et al.
        • ASGE Standards of Practice Committee
        The management of antithrombotic agents for patients undergoing GI endoscopy.
        Gastrointest Endosc. 2016; 83: 3-16
        • Kono Y.
        • Matsubara M.
        • Toyokawa T.
        • et al.
        Multicenter prospective study on the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users.
        Dig Dis Sci. 2017; 62: 730-738
        • Yuki T.
        • Ishihar