Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study

Safety of propofol sedation administered by an endoscopy team for outpatient colonoscopy

Sedation during colonoscopy increases comfort and reduces unexpected patient movement. Colorectal cancer (CRC) screening colonoscopies performed under propofol sedation controlled by our endoscopy team (ET) were retrospectively studied for eight months.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Sedation assisted by an endoscopist (SAE) for complex endoscopic procedures. Is it time to change the current guidelines?

Currently, sedation in endoscopic procedures is considered a necessary condition and a criterion of quality in digestive endoscopy. The role of SAE in conventional endoscopic procedures is clearly established in clinical guidelines, but this is not so clear in complex endoscopic procedures, such as ERCP. In recent years, numerous studies have been published, with results similar to those noticed in this article, endorsing the safety, efficacy and efficiency of SAE, when performed by properly trained staff.

Enhancing the current evidence on endoscopist-directed propofol-based sedation

During the last years, there is more and more scientific evidence about the safety and feasibility of non-anesthesiologist administration of propofol (NAAP) in gastrointestinal endoscopy, reducing sedation induction and recovery time as well as increasing patient and endoscopist satisfaction. Furthermore, a similar risk of adverse events compared with traditional agents or anesthesiologist administration of propofol (AAP) has been described. The present special issue of the Spanish Journal of Gastroenterology (Revista Española de Enfermedades Digestivas) focusses on NAAP in different settings, including complex endoscopic procedures.

Patient safety under deep sedation for digestive endoscopic procedures

Deep sedation with Propofol has become popular in recent years. The safety of this technique when administered by non-anaesthesiologists has created much controversy which at times is masked in a contentious debate on the economic sustainability of the health system. In 2011, the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy, along with 20 other organisations from European countries, revoked the recommendations of the European Society of Gastrointestinal Endoscopy on the administration of Propofol by non-anaesthesiologists, citing that it is "extremely dangerous for the safety and quality of endoscopic procedures". The FDA in 2005 had already rejected the use of Propofol by non-anaesthesiologists in the United States, a prohibition which was reiterated in 2010 and is still in force, basing its evidence, among others, on the recommendations and guidelines of the Joint Commission and the Declaration of Helsinki. In Spain, the data sheet of Propofol restricts the use of the drug to anaesthesiologists and intensivists in intensive care units. In our opinion, the key elements to discuss (which we develop in our paper) are those related to: a) the morbidity and mortality of sedation (which is the same as speaking about the factors that influence its safety); b) the appropriate professionals to use this technique; and c) economic aspects related to the use of said technique. Our conclusion is that a technique cannot be declared safe when a high percentage of patients present with varying respiratory depression (and therefore hypoxaemia) and hypotension. We are confident that the collaboration of the Spanish Society of Digestive Pathology and the Spanish Society of Digestive Endoscopy with the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy is the first step towards finding a satisfactory solution for everyone, and especially for our patients.

In response to the editorial "Sedation in endoscopy in 2016: Is it safe sedation with propofol led by the endoscopist in complex situations?"

It is universally accepted that deep sedation involves more risks than light-to-moderate sedation. Deep sedation for endoscopic explorations is normally provided by anesthesiologists in Spain and in most countries of the European Unión. The present debate about deep sedation-anesthesia states goes beyond the topic of cardiovascular and respiratory adverse events, and targets the cognitive consequences and global increased mortality of uncontrolled sedation states, especially in specific fragile populations. We consider that strong recomendations for sedative techniques in endoscopic procedures should be made in Spain taking in consideration to two basic principles: 1) according to published evidence concerning patient safety, deep sedation must be an unequivocal responsibility of the anesthesiologist, and 2) we must define which patients are candidates for deep sedation during endoscopic procedures, as this will help to regulate patient flow in clinics and to reduce adverse effects associated with overtreatment of patients.

Sedation for endoscopy in 2016 - Is endoscopist-guided sedation safe in complex situations?

The higher number of adverse events reported with anesthetist-delivered sedation are likely due to the fact that anethesia professionals induce deeper sedation as compared to sedation delivered by endoscopists. The former are trained to induce general anesthesia in their daily practice, where protective reflexes are more commonly depressed and the risk for undesired cardiopulmonary events is higher.