[S3-guidelines--sedation in gastrointestinal endoscopy]

Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

BACKGROUND AND AIM

There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA).

METHODS

Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I² statistics and publication bias by funnel plot and Egger regression testing.

RESULTS

Five studies (MAC: n = 1284 vs GETA: n = 615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P < 0.001) with no difference in Mallampati scores (P = 0.923). Procedure success, all-cause adverse events, and anesthesia-associated events were similar between groups [OR 1.16 (95% CI 0.51-2.64); OR 1.16 (95% CI 0.29-4.70); OR 1.33 (95% CI 0.27-6.49), respectively]. MAC resulted in fewer hypotensive episodes [OR 0.32 (95% CI 0.12-0.87], increased hypoxemic events [OR 5.61 (95% CI 1.54-20.37)], and no difference in cardiac arrhythmias [OR 0.48 (95% CI 0.13-1.78)]. Procedure time was decreased for MAC [standard difference - 0.39 (95% CI - 0.78-0.00)] with no difference in recovery time [standard difference - 0.48 (95% CI - 1.04-0.07)].

CONCLUSIONS

This study suggests MAC may be a safe alternative to GETA for ERCP; however, MAC may not be appropriate in all patients given an increased risk of hypoxemia.

Effects of transcutaneous electrical acupuncture point stimulation on peripheral capillary oxygen saturation in elderly patients undergoing colonoscopy with sedation: a prospective randomized controlled trial

INTRODUCTION

This study investigated whether transcutaneous electrical acupuncture point stimulation (TEAS) at PC6 can reduce the proportion of elderly patients experiencing a drop of ⩾4% in peripheral capillary oxygen saturation (SpO₂) while undergoing colonoscopy under sedation.

METHODS

A total of 32 elderly patients (aged ⩾ 65 years) scheduled for colonoscopy were randomly assigned in a 1:1 ratio to receive either real or sham TEAS (treatment or control groups, respectively). Each patient received oxygen (2 L/min) delivered routinely via nasal cannula. The treatment group was given TEAS at PC6 for 20 min at 2 Hz frequency and 6 mA intensity; the control group underwent the same procedures but with zero frequency/intensity. SpO₂ and other physiological parameters were measured prior to sedation and colonoscopy (baseline) and at seven other timepoints through departure from recovery. Depth of anesthesia was measured using a Narcotrend monitor.

RESULTS

Significantly fewer patients in the treatment group experienced a ⩾4% decrease from baseline SpO₂ (2/16) than patients in the control group (10/16; p = 0.004). The two groups were comparable with regard to respiratory rate, systolic and diastolic blood pressures, mean arterial pressure, and heart rate.

CONCLUSION

TEAS applied at PC6 with 2 Hz frequency was feasible and may be helpful in reducing the rate of hypoxia in elderly patients during colonoscopy.Trial registration number: NCT03775122 (ClinicalTrials.gov).

Predictor of respiratory disturbances during gastric endoscopic submucosal dissection under deep sedation

BACKGROUND

Sedation is commonly performed for the endoscopic submucosal dissection (ESD) of early gastric cancer. Severe hypoxemia occasionally occurs due to the respiratory depression during sedation.

AIM

To establish predictive models for respiratory depression during sedation for ESD.

METHODS

Thirty-five adult patients undergoing sedation using propofol and pentazocine for gastric ESDs participated in this prospective observational study. Preoperatively, a portable sleep monitor and STOP questionnaires, which are the established screening tools for sleep apnea syndrome, were utilized. Respiration during sedation was assessed by a standard polysomnography technique including the pulse oximeter, nasal pressure sensor, nasal thermistor sensor, and chest and abdominal respiratory motion sensors. The apnea-hypopnea index (AHI) was obtained using a preoperative portable sleep monitor and polysomnography during ESD. A predictive model for the AHI during sedation was developed using either the preoperative AHI or STOP questionnaire score.

RESULTS

All ESDs were completed successfully and without complications. Seventeen patients (49%) had a preoperative AHI greater than 5/h. The intraoperative AHI was significantly greater than the preoperative AHI (12.8 ± 7.6 events/h vs 9.35 ± 11.0 events/h, P = 0.049). Among the potential predictive variables, age, body mass index, STOP questionnaire score, and preoperative AHI were significantly correlated with AHI during sedation. Multiple linear regression analysis determined either STOP questionnaire score or preoperative AHI as independent predictors for intraoperative AHI ≥ 30/h (area under the curve [AUC]: 0.707 and 0.833, respectively) and AHI between 15 and 30/h (AUC: 0.761 and 0.778, respectively).

CONCLUSION

The cost-effective STOP questionnaire shows performance for predicting abnormal breathing during sedation for ESD that was equivalent to that of preoperative portable sleep monitoring.

Evaluation of bispectral index monitoring efficacy in endoscopic patients who underwent retrograde cholangiopancreatography and received sedoanalgesia

Introduction

Bispectral index (BIS) monitoring provides an objective, non-invasive measurement of the level of consciousness in a sedated patient.

Aim

In this prospective study, we aimed to investigate the hypothesis that risk of respiratory depression could be reduced and the desired level of sedation with minimal doses of propofol could be achieved by using BIS monitoring in endoscopic retrograde cholangiopancreatography (ERCP) procedures.

Material and methods

Sixty patients in the ASA 1–2 category, who were scheduled for an ERCP with sedation, were randomly divided into two groups. The procedure was performed, and sedation was administered so that the patient’s Ramsay Sedation Score (RSS) would be 4–5 in the first group (group 1) and the patient’s BIS value would be 65–75 in the second group (group 2). Cardiopulmonary complications, the total duration of the procedure, and the total amount of propofol administered were recorded.

Results

The mean SpO₂ measurements at the third minute, fifth minute, and 10^th minute were higher in the BIS group (p < 0.001) (p < 0.05). The mean number of respirations during the third, fifth, 10^th, and 15^th minute of sedation was significantly higher in the RSS group than in the BIS group (p < 0.05). There was no difference between the groups in terms of recovery time, total propofol amount, and additional doses of bolus propofol.

Conclusions

BIS monitoring during sedation with propofol for ERCP did not reduce total propofol use, but it may be an efficient guide for the timing of additional dose administration, which could reduce the risk of respiratory depression, and it could be used safely as an objective method in the follow-up of level of sedation.

Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study

Background

Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. To date, there is lack of consensus regarding who should administer sedation in these patients. Several studies have investigated the safety and efficacy of non-anesthesiologist-administered sedation for ERCP; however, data regarding anesthesiologist-administered sedation remain limited. This prospective single-center study investigated the safety and efficacy of anesthesiologist-administered sedation and the rate of successful performed ERCP procedures.

Methods

The study included 200 patients who underwent ERCP following anesthesiologist-administered sedation with propofol and remifentanil. Procedural data, oxygen saturation, systolic blood pressure (SBP), heart rate, recovery score, patient and endoscopist satisfaction, as well as 30-day mortality and morbidity data were analyzed.

Results

Sedation-related complications occurred in 36 of 200 patients (18%) and included hypotension (SBP < 90 mmHg) and hypoxemia (O₂ saturation < 90%) in 18 patients (9%) each. Most events were minor and did not necessitate discontinuation of the procedure. However, ERCP was terminated in 2 patients (1%) secondary to sedation-related complications. Successful cannulation was performed in all patients. The mean duration of the examination was 25 ± 16 min. Mean recovery time was 14 ± 10 min, and high post-procedural satisfaction was observed in both, patients (mean visual analogue scale [VAS] 9.6 ± 0.8) and endoscopists (mean VAS 9.3 ± 1.3).

Conclusion

This study suggests that anesthesiologist-administered sedation is safe in patients undergoing ERCP and is associated with a high rate of successful ERCP, shorter procedure time, and more rapid post-anesthesia recovery, with high patient and endoscopist satisfaction.

LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study

Background

Nonoperating room anesthesia during gastroenterological procedures is a growing field in anesthetic practice. While the numbers of patients with severe comorbidities are rising constantly, gastrointestinal endoscopic interventions are moving closer to minimally invasive endoscopic surgery. The LMA Gastro™ is a new supraglottic airway device, developed specifically for upper gastrointestinal endoscopy and interventions. The aim of this study was to evaluate the feasibility of LMA Gastro™ in patients with ASA physical status ≥3 undergoing advanced endoscopic procedures.

Methods

We analyzed data from 214 patients retrospectively who received anesthesia for gastroenterological interventions. Inclusion criteria were upper gastrointestinal endoscopic interventions, airway management with LMA Gastro™ and ASA status ≥3. The primary outcome measure was successful use of LMA Gastro™ for airway management and endoscopic intervention.

Results

Thirtyone patients with ASA physical status ≥3, undergoing complex and prolonged upper gastrointestinal endoscopic procedures were included. There were 7 endoscopic retrograde cholangiopancreatographies, 7 peroral endoscopic myotomies, 5 percutaneous endoscopic gastrostomies and 12 other complex procedures (e.g. endoscopic submucosal dissection, esophageal stent placement etc.). Of these, 27 patients were managed successfully using the LMA Gastro™. Placement of the LMA Gastro™ was reported as easy. Positive pressure ventilation was performed without difficulty. The feasibility of the LMA Gastro™ for endoscopic intervention was rated excellent by the endoscopists. In four patients, placement or ventilation with LMA Gastro™ was not possible.

Conclusions

We demonstrated the feasibility of the LMA Gastro™ during general anesthesia for advanced endoscopic procedures in high-risk patients.

Trial registration

German Clinical Trials Register (DRKS00017396) Date of registration: 23rd May 2019, retrospectively registered.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography

Background

Endoscopist-directed balanced propofol sedation (BPS) appears to be safe and effective for routine endoscopy. However, there are limited data on its use in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and efficacy of endoscopist-directed BPS for ERCP, and compared patient outcomes with anesthesiologist-administered moderate sedation.

Methods

This was a retrospective cohort study, using prospectively collected endoscopy data from a tertiary care medical center where endoscopist-directed BPS during ERCP is routine practice. Adverse outcomes included need for bag-mask ventilation or intubation, aborted ERCP due to sedation, hospital admission post-ERCP (outpatients)/change in the level of care (inpatients), and death within 24 h.

Results

A total of 501 patients underwent ERCP with the use of endoscopist-directed BPS: Cohort 1 - 380 (76%) inpatients, mean age 64.1, 46% male, 24% American Society of Anesthesiologists physical status (ASA) score I, 65% ASA II, 11% ASA III. Concurrently, 24 patients received anesthesiologist-administered moderate sedation: Cohort 2 - 19 (79%) inpatients, mean age 65.0, 67% male, 12% ASA I, 25% ASA II, 38% ASA III, 25% ASA IV. In Cohort 1, none of the adverse outcomes were observed. Propofol dose was inversely correlated with age (r=-0.42, P<0.001), ASA score (r=-0.19, P<0.001), and Mallampati score (r=-0.24, P<0.001). One patient in Cohort 2 who received anesthesiologist-administered BPS required bag-mask ventilation and the ERCP was prematurely aborted because of the sedation. There were no deaths from any cause within 24 h of ERCP.

Conclusion

Endoscopist-directed BPS appears safe, efficacious, and feasible for ASA I-III patients undergoing inpatient or ambulatory ERCP.

Safety and effectiveness of midazolam for cirrhotic patients undergoing endoscopic variceal ligation

BACKGROUND/AIMS

Endoscopic variceal ligation (EVL) is an established treatment for esophageal variceal bleeding. Midazolam (MDZ) is most commonly used for sedation during endoscopic procedures. However, adverse events (AEs) may occur more frequently in patients with cirrhosis due to altered MDZ metabolism.

MATERIALS AND METHODS

We retrospectively reviewed the records of 325 patients with cirrhosis who received EVL.

RESULTS

No significant differences were found in treatment outcome and procedure time among 151 patients in the MDZ group and 169 patients in the non-MDZ group. Desaturation (23.2% vs. 7.7%, p<0.01), bradycardia (22.5% vs. 17.2%, p=0.03), and hepatic encephalopathy (HE) (6.6% vs. 0.6%, p<0.01) were more common in the MDZ group than in the non-MDZ group. Logistic regression analyses revealed that an Eastern Cooperative Oncology Group (ECOG) score of ≥2 (p<0.01) and the use of MDZ (p<0.01) were associated with the development of overall AEs. An ECOG score of ≥2 (p=0.01), high serum creatinine level (p=0.02), and the use of MDZ (p<0.01) were significant risk factors for HE.

CONCLUSION

Extreme caution should be taken when sedating patients with cirrhosis receiving EVL due to the AEs associated with the use of MDZ.

Periprocedural Role of Nurses During Interventional Endoscopic Procedures Under Deep Sedation

Background. Most of endoscopic procedures, either diagnostic or therapeutic, are nowadays performed under sedation, used as a standard practice in most of the centers. Consequently, the number and complexity of endoscopic procedures has increased as sedation diminishes anxiety and discomfort for patients, also improving the quality of endoscopic examinations, and outcomes in therapeutic endoscopy. Compared to standard diagnostic upper or lower GI endoscopy, endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are often longer and more complicated procedures, thus requiring higher doses of sedatives. Sedation levels and medication types depend on a variety of factors, related both to patient characteristics (age, comorbidities, preference, etc.), and procedure types (simple diagnostic endoscopy or more complex therapeutic procedures). Propofol has become undoubtedly the induction agent of choice as it is easy to administer, enables prompt awakening, and has fewer side effects. Aim. The aim of this paper is to outline the role and efficacy of the endoscopy nurse in the peri-procedural care of patients undergoing complex therapeutic interventions (EUS-guided and/or ERCP) under propofol sedation. Methods. At our institution, the Research Centre of Gastroenterology and Hepatology Craiova, 192 patients underwent interventional endoscopic procedures between January 2014-December 2014 (130 EUS and 62 ERCP) under sedation with propofol. We included 110 patients in our study that were followed-up between 4 to 6 hours after the procedures. The GI nurse was responsible that the patients and/or their accompanying persons receive proper information in both written and spoken form regarding their procedure and potential adverse events after sedation. After the procedures the side effects related to anesthesia were marked down by the GI nurse based on a standard questionnaire. Results. The patients mean age was 53.5 years old, with 46 (41.8%) women and 64 (58.2%) men. Most of the patients, that is 90 (81.8%), presented no adverse events. The other 20 patients (18.2%) had the following side effects from sedation: drowsiness in 5 (4.5%) of the cases, nausea in 3 cases (2.8%), vomiting in one case (0.9%), 2 (1.8%) of the patients presented dizziness, 2 (1.8%) headache, 3 (2.8%) coughing, only one patient (0.9%) had an injection site reaction, one (0.9%) had shivers, and 2 patients (1.8%) presented bradycardia. Patients that had side effects were mainly of advanced age and with associated diseases which included chronic kidney disease, cardio-vascular diseases. The nurse responsible with the follow-up of patients was able to rapidly assess their complaints and intervene to the benefit of the patient, before serious adverse events could occur. Conclusions. Although propofol sedations is generally considered safe, potential side effects should be held in mind. The GI nurse has a valuable role in monitoring patients and assessing their response to sedation after the procedure, as well as in timely stepping in where necessary to prevent further complications.

Supraglottic jet oxygenation and ventilation enhances oxygenation during upper gastrointestinal endoscopy in patients sedated with propofol: a randomized multicentre clinical trial

Background

Hypoventilation is the main reason for hypoxia during upper gastrointestinal endoscopy procedures with sedation. The key to preventing hypoxia is to maintain normal ventilation during the procedure. We introduced supraglottic jet oxygenation and ventilation (SJOV) through a new Wei nasal jet tube (WNJ) to reduce the incidence of hypoxia in patients sedated with propofol during upper gastrointestinal endoscopy procedures.

Methods

In a multicentre, prospective randomized single-blinded study, 1781 outpatients undergoing routine upper gastrointestinal endoscopy who were sedated with propofol by an anaesthetist were randomized into the following three groups: the supplementary oxygen via nasal cannula group [nasal cannula oxygen: O 2 (2 litres min -1 ) was administered via a nasal cannula]; the supplementary oxygen via WNJ group [WNJ oxygen: O 2 (2 litres min -1 ) was administered through a WNJ]; and the SJOV via WNJ group (WNJ SJOV: SJOV was administered via WNJ) at three centres from March 2015 to July 2016. The primary outcome of interest was the incidence of hypoxia (peripheral oxygen saturation of 75-89%). Other adverse events were also recorded.

Results

Supraglottic jet oxygenation and ventilation decreased the incidence of hypoxia from 9 to 3% ( P <0.0001). No severe hypoxia occurred in the WNJ SJOV group, one instance occurred in the WNJ oxygen group, and two instances were observed in the nasal cannula oxygen supply control group. Supraglottic jet oxygenation and ventilation-related minor adverse events increased significantly within 1 min after the procedure but decreased 30 min later.

Conclusions

The use of SJOV during upper gastrointestinal endoscopy for patients who are sedated with propofol reduces the incidence of hypoxia, with minor and tolerable adverse events. Supraglottic jet oxygenation and ventilation has a favourable risk-to-benefit ratio and may improve patient safety.

Clinical trial registration

NCT02436018.

Propofol is a more effective and safer sedative agent than midazolam in endoscopic injection sclerotherapy for esophageal varices in patients with liver cirrhosis: a randomized controlled trial

OBJECTIVE

The efficacy of sedation during endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs) in patients with liver cirrhosis remains unclear. The aim of this study is to compare the efficacy and safety between propofol- and midazolam-based sedation for EIS.

METHODS

Twenty-three patients with EVs were prospectively and randomly assigned to midazolam-based (Midazolam group) or propofol-based (Propofol group) sedation. All patients underwent a number connection test (NCT) to evaluate minimal hepatic encephalopathy (MHE) on the day before and at 2 and 24 hours following EIS. The primary endpoint was exacerbation of MHE after EIS, which was defined as deterioration of the NCT. The secondary endpoints were postoperative awareness, technical success rate, frequency of body movement, patient and operator satisfaction, cardiorespiratory dynamics during EIS, and adverse events.

RESULTS

Exacerbations of MHE at 2 hours after EIS compared with those before EIS were not significantly different between the two groups. In both groups, the deterioration of NCT scores before and 2 hours after EIS was observed (Propofol group: 60.0 vs. 70.0 s, P = 0.026; Midazolam group: 42.5 vs. 67.0 s, P = 0.002). There were no significant differences in awareness, technical success rate, or patient satisfaction. However, the frequency of body movement in the Propofol group was significantly lower than that in the Midazolam group (1 vs. 4, P = 0.045), and operator satisfaction in the Propofol group was significantly higher than that in the Midazolam group (P = 0.016). No adverse events were observed.

CONCLUSIONS

Propofol-based sedation exacerbated MHE after EIS similarly to midazolam-based sedation in patients with liver cirrhosis. However, propofol-based sedation provided stable sedation with a lower frequency of body movements and high operator satisfaction.

The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis

Background

The use of capnography monitoring devices has been shown to lower the rates of hypoxemia via early detection of respiratory depression, and facilitate more accurate titration of sedatives during procedures. The aim of the current meta-analysis was to compare the incidence of hypoxemia associated with standard monitoring alone during gastrointestinal endoscopy to that associated with standard monitoring with the addition of capnography.

Methods

The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials scientific databases were searched to identify relevant studies. We performed a meta-analysis of randomized controlled trials undertaken up to January 2018 that met our predefined inclusion criteria. The study outcome measures were incidence of hypoxemia, severe hypoxemia, apnea, the use of assisted ventilation, the use of supplemental oxygen, and change in vital signs.

Results

We included nine trials assessing a total of 3,088 patients who underwent gastrointestinal procedural sedation. Meta-analysis of study outcome revealed that capnography significantly reduced the incidence of hypoxemia (odds ratio 0.61, 95% CI 0.49–0.77) and severe hypoxemia (odds ratio 0.53, 95% CI 0.35–0.81). However, there were no significant differences in other outcomes including incidence of apnea, assisted ventilation, supplemental oxygen, and changes in vital signs. Early procedure termination and patient satisfaction-related outcomes did not differ significantly in the capnography group and the standard monitoring group.

Conclusion

This study indicates that capnography monitoring is an important addition with regard to the detection of hypoxemia during gastrointestinal procedural sedation, and should be considered in routine monitoring during gastrointestinal endoscopy.

Leaving colorectal polyps in place can be achieved with high accuracy using blue light imaging (BLI)

Objectives

A negative predictive value of more than 90% is proposed by the American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) statement for a new technology in order to leave distal diminutive colorectal polyps in place without resection. To our knowledge, no prior prospective study has yet evaluated the feasibility of the most recently introduced blue light imaging (BLI) system for real-time endoscopic prediction of polyp histology for the specific endpoint of leaving hyperplastic polyps in place.

Aims

Prospective assessment of real-time prediction of colorectal polyps by using BLI.

Material and methods

In total, 177 consecutive patients undergoing screening or surveillance colonoscopy were included. Colorectal polyps were evaluated in real-time by using high-definition endoscopy and the BLI technology without optical magnification. Before resection, the endoscopist described each polyp according to size, shape and surface characteristics (pit and vascular pattern, colour and depression), and histology was predicted with a level of confidence (high or low).

Results

Histology was predicted with high confidence in 92.5% of polyps. Sensitivity of BLI for prediction of adenomatous histology was 92.68%, with a specificity and accuracy of 94.87 and 93.75%, respectively. Following the recommendation of the PIVI statement, positive and negative predictive values were calculated with values of 95 and 92.5%, respectively. Prediction of surveillance based on both US and European guidelines was correctly predicted in 91% of patients.

Conclusion

The most recently introduced BLI technology is accurate enough to leave distal colorectal polyps in place without resection. BLI also allowed for assignment of postpolypectomy surveillance intervals. This approach therefore has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.

Single-center implementation of endoscopic submucosal dissection (ESD) in the colorectum: Low recurrence rate after intention-to-treat ESD

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) shows higher R0 resection and lower local recurrence rates than endoscopic mucosal resection (EMR) in Japan. In Europe, independent learning of ESD in the colorectum is feasible, but yet to be analyzed for curative resection and recurrence rates.

METHODS

After experimental training under supervision by Japanese experts (T.O., N.Y.), three endoscopists independently carried out 83 ESD procedures intention-to-treat for lesions in the entire colorectum of 67 patients in a prospective registry (November 2009 to June 2016).

RESULTS

ESD was feasible in 80 (96%) colorectal neoplasias (mean diameter 33.6 [± 1.8] mm), and three more required conversion to piecemeal EMR. The lesions were adenomas in 66% with low-grade intraepithelial neoplasia (LGIN), 29% with high-grade intraepithelial neoplasia, and 5% with carcinomas (G2, pT1). ESD had to be facilitated by the final use of snaring (hybrid-ESD, n = 45), especially in the initial learning period. En-bloc resection rate was 85%. Complications were microperforations (7%, conducive to one hemicolectomy), and delayed bleeding (1%) without mortality or long-term morbidity. Residual adenomas with LGIN (5%) after hybrid-ESD did not recur after endoscopic ablation. All malignant neoplasias (34%) were curatively resected without recurrence after a mean follow up of 19.5 (± 3.2) months.

CONCLUSIONS

During independent ESD learning in the colorectum, ESD intention-to-treat showed a low recurrence rate after appropriate training, and hybrid-ESD showed acceptable complication and recurrence rates, justifying hybrid-ESD as a strategy for self-completion and rescue.

Survey of Anxiety in Ordinary Workers and Doctors Regarding Sedative Use during Endoscopic Examination in the Seoul Metropolitan Area

BACKGROUND/AIMS

Sedative use is common in endoscopic examinations. The anxiety regarding sedative use may be different between doctors and nonmedical individuals.

METHODS

A questionnaire survey was conducted by a research company (DOOIT Survey), and responses were collected from 649 doctors and 1,738 individuals who perform typical jobs in nonmedical fields. In this study, these ordinary workers are considered to represent nonmedical individuals. Anxiety was measured using a 5-point Likert scale.

RESULTS

The nonmedical individuals exhibited more anxiety regarding the sedative use than the doctors. Age <40 years (odds ratio [OR], 2.27; p<0.001), female sex (OR, 1.62; p=0.002), experience of an adverse event (OR, 1.79; p=0.049), and insufficient explanation (OR, 2.05; p<0.001) were the significant factors that increased the anxiety of the nonmedical individuals. The doctors who experienced a sedative-related adverse event reported increased anxiety compared with the doctors who did not report this experience (OR, 1.73; p=0.031).

CONCLUSIONS

Anxiety regarding sedative use during an endoscopic examination was significantly different between doctors and non-medical individuals. A younger age, female sex, an adverse event, and insufficient explanation affect the anxiety of nonmedical individuals. An adverse event also affects the anxiety of doctors.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett's neoplasia

BACKGROUND

For endoscopic resection of early GI neoplasia, endoscopic submucosal dissection (ESD) achieves higher rates of complete resection (R0) than endoscopic mucosal resection (EMR). However, ESD is technically more difficult and evidence from randomised trial is missing.

OBJECTIVE

We compared the efficacy and safety of ESD and EMR in patients with neoplastic Barrett's oesophagus (BO).

DESIGN

BO patients with a focal lesion of high-grade intraepithelial neoplasia (HGIN) or early adenocarcinoma (EAC) ≤3 cm were randomised to either ESD or EMR. Primary outcome was R0 resection; secondary outcomes were complete remission from neoplasia, recurrences and adverse events (AEs).

RESULTS

There were no significant differences in patient and lesion characteristics between the groups randomised to ESD (n=20) or EMR (n=20). Histology of the resected specimen showed HGIN or EAC in all but six cases. Although R0 resection defined as margins free of HGIN/EAC was achieved more frequently with ESD (10/17 vs 2/17, p=0.01), there was no difference in complete remission from neoplasia at 3 months (ESD 15/16 vs EMR 16/17, p=1.0). During a mean follow-up period of 23.1±6.4 months, recurrent EAC was observed in one case in the ESD group. Elective surgery was performed in four and three cases after ESD and EMR, respectively (p=1.0). Two severe AEs were recorded for ESD and none for EMR (p=0.49).

CONCLUSIONS

In terms of need for surgery, neoplasia remission and recurrence, ESD and EMR are both highly effective for endoscopic resection of early BO neoplasia. ESD achieves a higher R0 resection rate, but for most BO patients this bears little clinical relevance. ESD is, however, more time consuming and may cause severe AE.

TRIAL REGISTRATION NUMBER

NCT1871636.

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.

Acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy in patients without systemic sedation: results of a single-center, double-blinded, randomized controlled trial (DRKS00000164)

Background

Sedation prior to esophagogastroduodenoscopy is widespread and increases patient comfort. However, it demands additional trained personnel, accounts for up to 40 % of total endoscopy costs and impedes rapid hospital discharge. Most patients lose at least one day of work. 98 % of all serious adverse events occurring during esophagogastroduodenoscopy are ascribed to sedation. Acupuncture is reported to be effective as a supportive intervention for gastrointestinal endoscopy, similar to conventional premedication. We investigated whether acupuncture during elective diagnostic esophagogastroduodenoscopy could increase the comfort of patients refusing systemic sedation.

Methods

We performed a single-center, double-blinded, placebo-controlled superiority trial to compare the success rates of elective diagnostic esophagogastroduodenoscopies using real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic esophagogastroduodenoscopy who refused systemic sedation were eligible; 354 patients were randomized. The primary endpoint measure was the rate of successful esophagogastroduodenoscopies. The intervention was real or placebo acupuncture before and during esophagogastroduodenoscopy. Successful esophagogastroduodenoscopy was based on a composite score of patient satisfaction with the procedure on a Likert scale as well as quality of examination, as assessed by the examiner.

Results

From February 2010 to July 2012, 678 patients were screened; 354 were included in the study. Baseline characteristics of the two groups showed a similar distribution in all but one parameter: more current smokers were allocated to the placebo group. The intention-to-treat analysis included 177 randomized patients in each group. Endoscopy could successfully be performed in 130 patients (73.5 %) in the real acupuncture group and 129 patients (72.9 %) in the placebo group. Willingness to repeat the procedure under the same conditions was 86.9 % in the real acupuncture group and 87.6 % in the placebo acupuncture group.

Conclusions

Esophagogastroduodenoscopy without sedation is safe and can successfully be performed in two-thirds of patients. Patients planned for elective esophagogastroduodenoscopy without sedation do not benefit from acupuncture of the Sinarteria respondens (Rs) 24 Chengjiang middle line, Pericard (Pc) 6 Neiguan bilateral, or Dickdarm (IC) 4 Hegu bilateral, according to traditional Chinese medicine meridian theory.

Trial registration

DRKS00000164. Registered on 10 December 2009.

Anesthesia for endoscopic retrograde cholangiopancreatography: target-controlled infusion versus standard volatile anesthesia

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique used both for diagnosis and for the treatment of biliary and pancreatic diseases. ERCP has some anesthetic implications and specific complications. The primary outcome aim was to compare two protocols in terms of time of extubation. We also compared anesthetic protocols in terms of hemodynamic and respiratory instability, antispasmodics needs, endoscopist satisfaction, and recovery room stay.

METHODS

Patients were randomized into two groups standard anesthesia group (Gr: SA) in whom induction was done by propofol, fentanyl and cisatracurium and maintenance was done by a mixture of oxygen, nitrousoxide (50%:50%) and sevoflurane; and intravenous anesthesia group to target concentration (Gr: TCI) in whom induction and maintenance of anesthesia were done with propofol with a target 0.5-2 μg/mL, and remifentanil with a target of 0.75-2 ng/mL.

RESULTS

90 patients were included. Extubation time was shorter in Gr: TCI, 15±2.6 vs. 27.4±7.1 min in Gr: SA (P<0.001). The incidence of hypotension was higher in GrL: SA (P=0.009). Satisfaction was better in Gr: TCI (P=0.003). Antispasmodic need was higher in Gr: SA (P=0.023). Six patients in Gr: SA group had desaturation in post-anesthesia care unit (PACU) versus one patient from Gr: TCI (P=0.049). Patients in Gr: TCI had shorter PACU stay 40.2±7.3 vs. 58.7±12.4 min (P<0.001).

CONCLUSION

The use of TCI mode allows better optimization of general anesthesia technique during ERCP.

Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy

Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.

Prospective long-term assessment of sedation-related adverse events and patient satisfaction for upper endoscopy and colonoscopy

BACKGROUND

Fear of pain and sedation-related adverse events are impediments for patients to attend endoscopic screening or surveillance programs.

OBJECTIVE

To investigate the long-term effect of different sedation protocols in patients undergoing screening or surveillance endoscopy. Moreover, motivation of patients to decline endoscopic procedures was evaluated by focusing on the patient's satisfaction, fear and pain in relation to type of sedation used.

DESIGN

A prospective, double-blind controlled trial data collection was performed by using a standardized clinical questionnaire followed by a telephone interview 3-4 weeks after the initial endoscopic procedure.

SETTING

The study was conducted at the Department of Medicine I at the University Hospital of Erlangen-Nuremberg. Data collection was performed during June 2012 till April 2013.

PATIENTS

Overall, 307 patients were prospectively evaluated (44.3% female, mean age 51 ± 17.4 years; mean BMI 25.5 ± 5.7). 247 patients (80.5%) were outpatients, 60 inpatients (19.5%).

INTERVENTIONS

Endoscopic procedures were divided into five groups: (i) procedures in the upper gastrointestinal tract, (ii) complete colonoscopies, (iii) ileocolonoscopies, (iv) incomplete colonoscopies, and (v) other procedures.

MAIN OUTCOME MEASUREMENTS

Patient satisfaction, fear and pain were measured in a structured and standardized clinical interview using a 6-point numerical rating scale, where 1 was 'very satisfied/no pain' and 6 was 'very unsatisfied/unsupportable pain'.

RESULTS

Different types of sedation were assessed: propofol in monosedation (6.5%), combination of propofol + meperidine (41.0%), combination of midazolam + meperidine (48.5%) and other combinations (3.9%). Patient satisfaction was significantly reduced regarding fear and pain during the endoscopic procedure (p = 0.001 and p = 0.0001, respectively). All patients receiving propofol monosedation indicated significantly less pain in comparison to other sedation groups (p < 0.0001). Moreover, sedation with midazolam + meperidine increased the fear during the procedure significantly in comparison to monosedation with propofol (p = 0.082). Propofol/meperidine in combination and midazolam/meperidine increased the probability for cardiovascular events in comparison to monosedation with propofol (p = 0.005; p = 0.039). Finally, we observed significantly lower doses of propofol when used in monosedation than propofol in combination with meperidine (p = 0.066).

LIMITATION

Single-center study at a tertiary referral center.

CONCLUSIONS

Propofol in monosedation should preferably be used for patient sedation in screening and surveillance endoscopies. Whether this approach could also improve participation rates in screening and surveillance endoscopies requires further investigations.

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

BACKGROUND AND STUDY AIMS

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

METHODS

We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

RESULTS

The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

CONCLUSIONS

Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial

BACKGROUND

Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods.

METHODS

One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient's pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications.

RESULTS

Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups.

CONCLUSION

Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01806753.

Gastrointestinal endoscopy in patients aged 75 years and older: risks, complications, and findings--a retrospective study

PURPOSE

Endoscopy of the gastrointestinal tract offers simultaneously diagnostic and therapeutic options and is increasingly performed in elderly patients due to a continuously growth of this population segment. Whereas safety data of diagnostic and interventional endoscopy in patients younger than 65 years are well characterized, only scarce data exist for elderly patients older than 75 years.

METHODS

We analyzed outcomes and complications of endoscopic procedures with focus on colonoscopy in patients aged 75 and older at a single tertiary referral center in Germany between 1996 and 2006.

RESULTS

A total of 3770 endoscopies (2270 gastroscopies, 735 colonoscopies, 765 ERCP) were performed in 1841 patients with a mean age of 79 years (range 75 to 97 years). Seventy-four percent of all patients suffered from relevant comorbidities. Therapeutic interventions were carried out in 43 % of colonoscopies. Complications were observed in approximately 1 %.

CONCLUSION

The observed complication rate in diagnostic and therapeutic endoscopic procedures is not increased in elderly patients compared to the reported complication rates in younger patients.

Endoscopic sedation and monitoring practices in Portugal: a nationwide web-based survey

BACKGROUND

National surveys have been used to obtain information on sedation and monitoring practices in endoscopy in several countries.

AIMS

To provide data from Portugal and query the Portuguese endoscopists on nonanesthesiologist administration of propofol.

MATERIALS AND METHODS

A 31-item web survey was sent to all 490 members of the Portuguese Society of Gastroenterology.

RESULTS

A total of 129 members (26%) completed the questionnaire; 57% worked in both public and private practice. Most performed esophagogastroduodenoscopy without sedation (public - 70%; private - 57%) and colonoscopies with sedation (public - 64%; private - 69%). Propofol was the most commonly used agent for colonoscopy, especially in private practice (52 vs. 33%), and it provided the best satisfaction (mean 9.6/10). A total of 94% chose propofol as the preferred sedation for routine colonoscopy. Nonanesthesiologist administration of propofol was performed only by four respondents; however, 71% reported that they would consider its use, given adequate training. Pulse oximetry is monitored routinely (99%); oxygen supplementation is administered by 81% with propofol and 42% with traditional sedation. Most (82%) believed that propofol sedation may increase the uptake of endoscopic screening for colorectal cancer.

CONCLUSION

The use of sedation is routine practice in colonoscopy, but not esophagogastroduodenoscopy. The preferred agent is propofol and it is used almost exclusively by anesthesiologists.

Untutored learning curve to establish endoscopic submucosal dissection on competence level

BACKGROUNDS/AIMS

Endoscopic submucosal dissection (ESD) of early cancer allows precise staging and avoids recurrence or surgery. Tutored by experts, ESD has rapidly spread in Japan, but still demands untutored learning in Western countries. A step-up approach starts with easiest gastric neoplasias, but fails on their low prevalence in Western countries. A prevalence-based approach includes challenging colonic neoplasias.

METHODS

We analyzed an untutored series of initial 50 ESD procedures by an experienced endoscopist on consecutive lesions referred according to prevalence.

RESULTS

Overall, 48 lesions (20% upper gastrointestinal, 80% colorectal; 2 hyperplastic (inflammatory) lesions, 46 neoplasms) were completely resected intention-to-treat with ESD, 2 required a second ESD. Neoplasias were resected 76% en-bloc (46% ESD, 30% ESD with snaring), 17% by ESD with snaring in 2-3 pieces, and 6.5% as ESD with snaring in multiple pieces. None of 15 neoplasias with high-grade intraepithelial neoplasia or an early esophageal cancer (R0) had recurred. Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated. All patients were discharged within 9 days without long-term morbidity.

CONCLUSION

Untutored learning of ESD is feasible on colonic lesions. We propose to establish ESD in Europe with structured training and a prevalence-of-lesions-based approach.

New aspects in the pathomechanism and diagnosis of the laryngopharyngeal reflux-clinical impact of laryngeal proton pumps and pharyngeal pH metry in extraesophageal gastroesophageal reflux disease

AIM: To determine the laryngeal H+K+-ATPase and pharyngeal pH in patients with laryngopharyngeal reflux (LPR)-symptoms as well as to assess the symptom scores during PPI therapy.

METHODS: Endoscopy was performed to exclude neoplasia and to collect biopsies from the posterior cricoid area (immunohistochemistry and PCR analysis). Immunohistochemical staining was performed with monoclonal mouse antibodies against human H+K+-ATPase. Quantitative real-time RT-PCR for each of the H+K+-ATPase subunits was performed. The pH values were assessed in the aerosolized environment of the oropharynx (DxpH Catheter) and compared to a subsequently applied combined pH/MII measurement.

RESULTS: Twenty patients with LPR symptoms were included. In only one patient, the laryngeal H+K+-ATPase was verified by immunohistochemical staining. In another patient, real-time RT-PCR for each H+K+-ATPase subunit was positive. Fourteen out of twenty patients had pathological results in DxpH, and 6/20 patients had pathological results in pH/MII. Four patients had pathological results in both functional tests. Nine out of twenty patients responded to PPIs.

CONCLUSION: The laryngeal H+K+-ATPase can only be sporadically detected in patients with LPR symptoms and is unlikely to cause the LPR symptoms. Alternative hypotheses for the pathomechanism are needed. The role of pharyngeal pH-metry remains unclear and its use can only be recommended for patients in a research study setting.

Endoscopic sedation: from training to performance

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices

BACKGROUND AND AIM

Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology.

METHODS

In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure.

RESULTS

In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation.

CONCLUSION

Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.

Intratumoral Mistletoe (Viscum album L) Therapy in Patients With Unresectable Pancreas Carcinoma: A Retrospective Analysis

Pancreatic carcinoma remains one of the main causes for cancer-related death. Intratumoral application of anticancer agents is discussed as a promising method for solid tumors such as pancreatic cancer. Endoscopic ultrasound provides a good tool to examine and treat the pancreas. European mistletoe (Viscum album L) is a phytotherapeutic commonly used in integrative oncology in Central Europe. Its complementary use seeks to induce immunostimulation and antitumoral effects as well as alleviate chemotherapeutic side effects. Intratumoral mistletoe application has induced local tumor response in various cancer entities. This off-label use needs to be validated carefully in terms of safety and benefits. Here we report on 39 patients with advanced, inoperable pancreatic cancer, who received in total 223 intratumoral applications of mistletoe, endoscopic ultrasound guided or under transabdominal ultrasound control. No severe procedure-related events were reported. Adverse drug reactions were mainly increased body temperature or fever in 14% and 11% of the applications, respectively. Other adverse drug reactions, such as pain or nausea, occurred in less than 7% of the procedures. No severe adverse drug reaction was recorded. Patients received standard first- and second-line chemotherapy and underwent adequate palliative surgical interventions as well as additive subcutaneous and partly intravenous mistletoe application. A median survival of 11 months was observed for all patients, or 11.8 and 8.3 months for stages III and IV, respectively. Due to the multimodal therapeutic setting and the lack of a control group, the effect of intratumoral mistletoe administration alone remains unclear. This retrospective analysis suggests that intratumoral-applicated mistletoe might contribute to improve survival of patients with pancreatic cancer. In conclusion, the application is feasible and safe, and its efficacy should be evaluated in a randomized controlled trial.

Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher

INTRODUCTION

The German guideline for sedation in gastrointestinal endoscopy was published in 2008. Several recommendations in this guideline, especially concerning staffing and structural requirements for sedation, have low evidence and therefore are subject to discussion in the field.

AIM

Comparison of endoscopic complications in a department specialized for gastrointestinal and pulmological diseases before and after implementation of the German guideline grouped in sedation-associated and non-sedation-associated complications.

METHODS

Prospective documentation of complications with retrospective analysis of two patient groups (before guideline: 1.5.2008-30.4.2010; after guideline: 1.5.2010-30.4.2012) at which the sedation technique remained the same (balanced propofol sedation, BPS).

RESULTS

Both investigation periods covered almost 7000 procedures. Interventional and general complications were nonsignificantly elevated in the latter group (1.27% before vs. 1.55% after guideline, p = 0.08). Saturation decline (in both groups 0.26%) was unchanged, and circulation-associated complications (0.27% vs. 0.13%, p = 0.07) were reduced nonsignificantly. Necessity for the administration of flumazenil and for intensive care monitoring was reduced in a nonsignificant manner after the implementation of the guideline. Severe complications (reanimation, apnea, and death) were unchanged, and no patient with ASA I-II suffered from a severe complication. Propofol consumption was higher after guideline implementation.

CONCLUSIONS

The recommendations of the new German sedation guideline do not significantly reduce complications in endoscopic procedures. Especially, procedures involving patients with ASA classes I and II do not require an additional staff member solely for sedation. Prospective randomized studies might be necessary to optimize the utilization of resources.

Low effect-site concentration of propofol target-controlled infusion reduces the risk of hypotension during endoscopy in a Taiwanese population

OBJECTIVE

Target-controlled infusion (TCI) of propofol is an effective way of delivering propofol during endoscopy. However, the ideal effect-site concentration (Ce) of propofol has not yet been defined in an Asian population. This study aimed to determine the ideal Ce of propofol in painless gastrointestinal endoscopy in a Taiwanese population.

METHODS

A total of 121 consecutive patients undergoing diagnostic endoscopy were recruited for this study. The endoscopic procedure was carried out within 1 h. TCI of propofol was utilized during the procedure. All patients received the same regimen to induce conscious sedation, including a bolus of midazolam (0.04 mg/kg) and fentanyl (0.5 μg/kg). The Ce of propofol was calculated using the Schneider model. Patients were randomly assigned to either the low Ce group (1.5-2.5 μg/mL) or high Ce group (3.0-4.0 μg/mL). Their cardiovascular and respiratory events were monitored during the procedure and the patients' post-procedure satisfaction was evaluated.

RESULTS

The mean requirement for propofol was 232.02 mg in the low Ce group and 329.56 mg in the high Ce group, respectively (P < 0.0001). No unexpected event was observed in either group. However, more episodes of hypotension were observed in the high Ce group (P = 0.026). The post-procedure satisfaction rate between the two groups was comparable.

CONCLUSION

A low Ce of propofol TCI (1.5-2.5 μg/mL) achieved adequate anesthesia, reduced the risk of hypotension, and attained a high satisfaction rate in a Taiwanese population undergoing diagnostic painless endoscopy.

[Foreign bodies in ENT medicine]

A foreign body (Latin: corpus alienum) is any object originating outside the body. Of all specialties, otolaryngology covers the greatest number of natural body orifices, making foreign bodies a common diagnosis. Foreign bodies of the ear canal and nose often occur in children and are easily accessible during physical examination. Foreign bodies of the oral cavity and oropharynx are also easily removed. Esophageal and tracheobronchial foreign bodies are common in children and the elderly. A number of rigid and flexible endoscopic techniques are available for foreign body removal. In Germany, flexible endoscopy is six times more common than rigid endoscopy. Both methods are highly effective, and each has its advantages in certain situations. Rigid endoscopy is still a key in otolaryngology and can be used in case of failure of flexible techniques. It is therefore important for otolaryngologists to be proficient in both techniques.

Präventionschecklisten im OP und in der Endoskopie

<b><i>Hintergrund: </i></b>Unerwünschte Ereignisse oder sogar folgenschwere Fehlleistungen entstehen in der Medizin nicht zufällig. Analog zu anderen hochriskanten Arbeitswelten wie der Luftfahrt oder der Kernenergie stellen sie eine Verkettung unglücklicher Umstände bzw. den Zusammenbruch der Multibarrierenstrategie dar. Aus diesem Grund wurden im Laufe der letzten Jahre Checklisten etabliert, die als Teil dieser Sicherheitsbarrieren die Patientensicherheit erhöhen. <b><i>Methode: </i></b>Zur Literaturrecherche wurden die Datenbanken von Medline und PubMed sowie der Internetsuchdienst von Google unter den Suchworten «Checkliste», «Sicherheitscheckliste», zum Teil kombiniert mit «Endoskopie» bzw. «Endoscopy», «Surgical Safety Checklist», «Safety Checklist», «Checklist», «Safety Management» und «WHO-Checklist(e)» abgefragt. Die so identifizierten Publikationen wurden im Folgenden auf die relevanten endoskopischen und chirurgischen Belange hin zusammengestellt und um eigene Erfahrungen aus der Chirurgie und Endoskopie ergänzt. <b><i>Ergebnisse: </i></b>Operationschecklisten sind nachweislich effektive Instrumente zur Erhöhung der Patientensicherheit und Vermeidung von unerwünschten Ereignissen. Dies ist insbesondere auf eine verbesserte Kommunikation bzw. Teaminteraktion zurückzuführen, mit dem Effekt einer dadurch veränderten Sicherheitskultur. Voraussetzung ist ein gutes Checklistendesign und die gelebte Anwendung der Checklisten durch die Leitungsebenen. <b><i>Schlussfolgerungen: </i></b>Operationssaal(OP)-Checklisten verbessern nachhaltig die Sicherheitskultur und erhöhen dadurch die Patientensicherheit. Diese positiven Ergebnisse sollten zunehmend in andere Bereiche der Medizin wie die Endoskopie transferiert werden.

Patientensicherheit in der Endoskopie: Prävention und Management von kritischen Ereignissen bei der Sedierung

<b><i>Hintergrund: </i></b>Die Verbesserung der Patientensicherheit in der Endoskopie ist nicht einfach und nicht von heute auf morgen zu realisieren. Der größte Anteil an schwerwiegenden Zwischenfällen bei der Endoskopie ist auf die Sedierung zurückzuführen. <b><i>Methode: </i></b>Anwendung der Inhalte der S3-Leitlinie sowie aktueller Kenntnisse zur Erhöhung der Patientensicherheit. <b><i>Ergebnisse: </i></b>Es ist selbstverständlich, dass die gemäß der aktuellen S3-Leitlinie geforderten Personal-, Struktur- und Prozessvoraussetzungen bei einer Sedierung in der Endoskopie auch bei Personalknappheit kompromisslos eingehalten werden. Risikopatienten müssen zuverlässig identifiziert und dann von entsprechend (intensivmedizinisch) erfahrenem Personal während endoskopischer Eingriffe betreut werden. Dennoch gilt: Fehler sind in komplexen Systemen zu erwarten und insofern «normal». Aber wir müssen aus Fehlern lernen. Hierfür bieten moderne softwarebasierte «Critical Incident Reporting»-Systeme (CIRS) gute Voraussetzungen. 70% der medizinischen Fehler beruhen nicht auf mangelndem Fachwissen, sondern auf Problemen im Bereich der Human Factors (HFs). Crisis Resource Management (CRM) ist ein effektives Tool gegen HF-bedingte Fehler und sollte in Zukunft von allen beherrscht werden. <b><i>Schlussfolgerungen: </i></b>Der aktuelle Goldstandard für HF/CRM-Training ist der Einsatz von realitätsnahen und modernen Simulationsteamtrainings, die von speziell geschulten Instruktoren durchgeführt werden. Um die Patientensicherheit nachhaltig zu erhöhen, sind die Autoren der Auffassung, dass Simulationstrainings zu Sedierungen und Zwischenfällen in der Endoskopie mindestens zweimal pro Jahr für jeden medizinischen Mitarbeiter bei Sedierungen in der Endoskopie durchgeführt werden sollten.

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.

Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: a randomized, controlled study (ColoCap Study)

OBJECTIVES

The aim of this randomized study was to determine whether intervention based on additional capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol sedation for colonoscopy.

METHODS

Patients (American Society of Anesthesiologists classification (ASA) 1-3) scheduled for colonoscopy under propofol sedation were randomly assigned to either a control arm with standard monitoring (standard arm) or an interventional arm in which additional capnographic monitoring (capnography arm) was available. In both study arms, detection of apnea or altered respiration induced withholding propofol administration, stimulation of the patient, chin lift maneuver, or further measures. The primary study end point was the incidence of arterial oxygen desaturation (defined as a fall in oxygen saturation (SaO(2)) of ≥5% or <90%); secondary end points included the occurrences of hypoxemia (SaO(2) <90%), severe hypoxemia (SaO(2) ≤85%), bradycardia, hypotension, and the quality of sedation (patient cooperation and patient satisfaction).

RESULTS

A total of 760 patients were enrolled at three German endoscopy centers. The intention-to-treat analysis revealed a significant reduction of the incidence of oxygen desaturation in the capnography arm in comparison with the standard arm (38.9% vs. 53.2%; P<0.001). The numbers of patients with a fall in SaO(2) <90% and ≤85% were also significantly different (12.5% vs. 19.8%; P=0.008 and 3.7 vs. 7.8%; P=0.018). There were no differences regarding the rates of bradycardia and hypotension. Quality of sedation was similar in both groups. Results of statistical analyses were maintained for the per-protocol population.

CONCLUSIONS

Additional capnographic monitoring of ventilatory activity reduces the incidence of oxygen desaturation and hypoxemia during propofol sedation for colonoscopy.

Analgesia without sedatives during colonoscopies: worth considering?

Colonoscopy is a proven method for bowel cancer screening and is often experienced as a painful procedure. Today, there are two main strategies to facilitate colonoscopy. First, deep sedation results in satisfied patients but increases sedation-associated risks and raises costs for healthcare providers. Second, there is the advocacy for colonoscopies without any form of sedation. This might be an option for a special group of patients, but does not hold true for everybody. Following Moerman’s hypothesis: “If pain is the crucial point, why do we need sedation?” this review shows the analgesic options for a painless procedure, increasing success rates without increasing risk of sedation. There are two agents, with the potential to be a nearly ideal analgesic agent for colonoscopy: alfentanil and nitrous oxide (N₂O). Administration of either substance causes the patient to be comfortable yet alert and facilitates a short turnover. Advantages of these drugs include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level, rapid recovery, and an excellent safety profile.

First agreement analysis and day-to-day comparison of pharyngeal pH monitoring with pH/impedance monitoring in patients with suspected laryngopharyngeal reflux

OBJECTIVE

Diagnosis of laryngopharyngeal reflux (LPR) is still challenging. Recently a diagnostic device for pH values in the aerosolized environment of the pharynx has been introduced (Dx-pH). We evaluated results of Dx-pH with objective criteria of pH/impedance monitoring (MII) and subjective reflux scoring systems and assessed day-to-day variability.

DESIGN

This study makes use of a prospective single-center trial. Thirty patients with suspected LPR were analyzed. Upper endoscopic examination, manometry, phoniatric examination, and reflux scores were assessed. Dx-pH was performed on two consecutive days, first in combination with MII and second as single measurement. Thereafter, proton pump inhibitor (PPI) trial was performed. Patients were interviewed about symptom relief after 3 months.

RESULTS

There were considerable differences between MII and results on Dx-pH: day 1 (agreement 11 out of 30, kappa 0.137) and day 2 (agreement 14 out of 30, kappa 0.036). Statistically significant differences were detected correlating all single reflux episodes (n = 453) of Dx-pH with MII and vice versa. Furthermore acidic reflux episodes did not result in pH drops of the pharynx. There was a fair agreement between Dx-pH measurements on subsequent days. After follow-up, 3 out of 18 patients with pathological Dx-pH results reported positive response to PPIs, in contrast to 5 out of 6 patients with pathological MII.

CONCLUSION

According to our data, acid pharyngeal pH levels detected with Dx-pH are not related to GERD and acid esophageal reflux episodes do not result in pharyngeal pH alterations. Hence, present etiology of LPR needs to be reconsidered since neither mixed nor gas reflux events result in pharyngeal pH alteration. Other acid-producing or retaining factors should be taken into account.

Endoscopic submucosal dissection of early gastric neoplasia with a water jet-assisted knife: a Western, single-center experience

BACKGROUND

Endoscopic submucosal dissection (ESD) of early gastric neoplasia has not yet been established in Western countries because of a lack of data and the difficult, time-consuming, and hazardous nature of the method. Some of the technical limitations may be overcome by use of a water jet-assisted knife, which allows a combination of a high-pressure water jet and electrosurgical interventions.

OBJECTIVE

To evaluate the efficacy and safety of water jet-assisted ESD (WESD) with a water jet-assisted knife in selected patients with early gastric neoplasia.

DESIGN

Single-center, prospective study.

PATIENTS

This study involved 29 consecutive patients (13 female; median age 61 years; age range 35-93 years) with early gastric neoplasia that met the expanded criteria of the Japanese Gastric Cancer Association. Histology of biopsies had shown gastric adenocarcinoma in 21 cases, adenoma in 8 case, and suspicion of a GI stromal tumor in 1 case. The median maximal diameter of the lesions was 20 mm (range 10-40 mm).

INTERVENTION

All procedures were done with patients under sedation with propofol. The water jet-assisted knife was used for setting coagulation markers around the neoplastic lesions, then for circumferential incision and dissection in combination with repeated submucosal injection of saline solution with a water jet system. Bleeding was treated with diathermia by use of the water jet-assisted knife or hemostatic forceps in case of failure or larger vessels. Clips were used for closure of perforations.

MAIN OUTCOME MEASUREMENTS

Complete resection of neoplasia, procedure time, complication and recurrence rates.

RESULTS

According to endoscopic criteria, complete resection of the targeted area could be achieved in all cases, with an en bloc resection rate of 90%. The median procedure duration was 74 minutes (range 15-402 minutes). Exchange of the device was needed in only 10 cases because of severe bleeding from larger vessels, which could be managed by use of hemostatic forceps. The 30-day morbidity rate was 4 of 30 (13.8%) because of postprocedure pain in 3 cases and delayed bleeding in 1 case. A 93-year-old patient died the night after WESD without evidence of a procedure-related complication. Histology of the resected specimens showed adenocarcinoma in 20 cases, adenoma in 7, no neoplasia in 2, and a plasmacytoma in 1. Complete resection (R0) was histologically confirmed in 18 of 28 patients (64.3%) with resected neoplastic specimens. A horizontal or vertical neoplasia-free margin could not be confirmed in 9 cases and 1 case, respectively. Complete local remission of neoplasia was achieved in 25 of 28 patients (89.3%) who were followed over a median period of 22 months (range 6-44 months). In 1 patient, a metachronous gastric adenocarcinoma was identified 54 weeks after initial WESD.

LIMITATIONS

Noncontrolled study with a limited number of patients.

CONCLUSION

The use of a water jet-assisted knife simplifies ESD because exchange of devices is rarely needed. WESD promises to be effective and safe. The study demonstrates that the high rates of en bloc resection of early gastric neoplasia reported in Asia can be reproduced in Western referral centers. However, histology may not always confirm complete resection of horizontal tumor margins. In spite of the unfavorable histology results, the high rate of complete local remission of neoplasia promises that surgical treatment of early gastric neoplasia can be avoided in the majority of cases.

[Local anesthetic procedures in dermatology. Part 2: Practical aspects]

The vast majority of dermatologic surgery is performed with local anesthesia. The different methods provide safe and effective analgesia in circumscribed areas of skin and subcutaneous tissue and allow patients to tolerate otherwise painful diagnostic or therapeutic procedures while remaining conscious. Some forms of local anesthesia are unique, such as topical anesthesia with EMLA® or cryoanesthesia; others offer options to general anesthesia. Tumescent local anesthesia has gained widespread acceptance in the past decade for many indications other than cosmetic liposuction and is used for excising benign and malignant tumors, for extensive skin and soft tissue procedures (such as excision of acne inversa or sweat gland curettage) and in phlebologic surgery.

Latest generation, wide-angle, high-definition colonoscopes increase adenoma detection rate

BACKGROUND & AIMS

Improvements to endoscopy imaging technologies might improve detection rates of colorectal cancer and patient outcomes. We compared the accuracy of the latest generation of endoscopes with older generation models in detection of colorectal adenomas.

METHODS

We compared data from 2 prospective screening colonoscopy studies (the Berlin Colonoscopy Project 6); each study lasted approximately 6 months and included the same 6 colonoscopists, who worked in private practice. Participants in group 1 (n = 1256) were all examined by using the latest generation of wide-angle, high-definition colonoscopes that were manufactured by the same company. Individuals in group 2 (n = 1400) were examined by endoscopists who used routine equipment (a mixture of endoscopes from different companies; none of those used to examine group 1). The adenoma detection rate was calculated on the basis of the number of all adenomas/number of all patients.

RESULTS

There were no differences in patient parameters or withdrawal time between groups (8.0 vs 8.2 minutes). The adenoma detection rate was significantly higher in group 1 (0.33) than in group 2 (0.27; P = .01); a greater number of patients with least 1 adenoma were identified in group 1 (22.1%) than in group 2 (18.2%; P = .01). A higher percentage of high-grade dysplastic adenomas were detected in group 1 (1.19%) than in group 2 (0.57%), but this difference was not statistically significant (P = .06).

CONCLUSIONS

The latest generation of wide-angle, high-definition colonoscopes improves rates of adenoma detection by 22%, compared with mixed, older technology endoscopes used in routine private practice. These findings might affect definitions of quality control parameters for colonoscopy screening for colorectal cancer.

[Local anesthetic procedures in dermatology: Part 1: principles]

Most dermatologic surgery is performed under local anesthesia. The choice of the type of anesthesia depends on the age, ability to cooperate and comorbidities of the patient. Anesthetics of the amide type are generally preferred for local infiltration. A solid anatomic background is required to perform effective peripheral nerve blocks. If the methods of action, toxic effects and potential drug interactions are considered, then local anesthetics have a low risk of complications. One must also not overlook the need for regular training in managing anesthetic emergencies for the entire operating room team, especially with the increasing age of our patients.