Atypical presentations and pitfalls of achalasia

Achalasia is a rare disease with significant diagnostic delay and association with false diagnoses and unnecessary interventions. It remains unclear, whether atypical presentations, misinterpreted symptoms or inconclusive diagnostics are the cause. The aim of this study was the characterization of typical and atypical features of achalasia and their impact on delays, misinterpretations or false diagnoses. A retrospective analysis of prospective database over a period of 30 years was performed. Data about symptoms, delays and false diagnoses were obtained and correlated with manometric, endoscopic and radiologic findings. Totally, 300 patients with achalasia were included. Typical symptoms (dysphagia, regurgitation, weight loss and retrosternal pain) were present in 98.7%, 88%, 58.4% and 52.4%. The mean diagnostic delay was 4.7 years. Atypical symptoms were found in 61.7% and led to a delay of 6 months. Atypical gastrointestinal symptoms were common (43%), mostly 'heartburn' (16.3%), 'vomiting' (15.3%) or belching (7.7%). A single false diagnosis occurred in 26%, multiple in 16%. Major gastrointestinal misdiagnoses were GERD in 16.7% and eosinophilic esophagitis in 4%. Other false diagnosis affected ENT-, psychiatric, neurologic, cardiologic or thyroid diseases. Pitfalls were the description of 'heartburn' or 'nausea'. Tertiary contractions at barium swallows, hiatal hernias and 'reflux-like' changes at endoscopy or eosinophils in the biopsies were misleading. Atypical symptoms are common in achalasia, but they are not the sole source for diagnostic delays. Misleading descriptions of typical symptoms or misinterpretation of diagnostic studies contribute to false diagnoses and delays.

Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial

BACKGROUND & AIMS

Swallowed topical-acting corticosteroids are recommended as first-line therapy for eosinophilic esophagitis (EoE). Asthma medications not optimized for esophageal delivery are sometimes effective, although given off-label. We performed a randomized, placebo-controlled trial to assess the effectiveness and tolerability of a budesonide orodispersible tablet (BOT), which allows the drug to be delivered to the esophagus in adults with active EoE.

METHODS

We performed a double-blind, parallel study of 88 adults with active EoE in Europe. Patients were randomly assigned to groups that received BOT (1 mg twice daily; n = 59) or placebo (n = 29) for 6 weeks. The primary end point was complete remission, based on clinical and histologic factors, including dysphagia and odynophagia severity ≤2 on a scale of 0-10 on each of the 7 days before the end of the double-blind phase and a peak eosinophil count <5 eosinophils/high power field. Patients who did not achieve complete remission at the end of the 6-week double-blind phase were offered 6 weeks of open-label treatment with BOT (1 mg twice daily).

RESULTS

At 6 weeks, 58% of patients given BOT were in complete remission compared with no patients given placebo (P < .0001). The secondary end point of histologic remission was achieved by 93% of patients given BOT vs no patients given placebo (P < .0001). After 12 weeks, 85% of patients had achieved remission. Six-week and 12-week BOT administration were safe and well tolerated; 5% of patients who received BOT developed symptomatic, mild candida, which was easily treated with an oral antifungal agent.

CONCLUSIONS

In a randomized trial of adults with active EoE, we found that budesonide oral tablets were significantly more effective than placebo in inducing clinical and histologic remission. Eudra-CT number 2014-001485-99; ClinicalTrials.gov ID NCT02434029.

Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25 years with a focus on manometric subtypes

BACKGROUND AND AIM

Pneumatic dilation (PD) is the most popular nonsurgical treatment for achalasia. This study investigated predicting factors, including manometric subtypes for symptom recurrence in the long term, in patients with achalasia treated with a single PD.

METHODS

Between 1983 and 2013, a total of 107 patients were treated initially with a single PD and included in this longitudinal cohort study. Outcomes were correlated with demographics, symptoms (Eckardt score), and esophagographic and manometric features. Manometric tracings were retrospectively classified according to the three subtypes of the Chicago classification.

RESULTS

Ninety-one (85%) patients were successfully treated after the first PD. The median follow-up was 13.8 years (interquartile range 7-20). During follow-up, 54% of the patients experienced a clinical relapse. The overall cumulative success rates at 2, 5, 10, 15, 20, and 25 years were 64%, 53%, 49%, 42%, 36%, and 36%, respectively. Age < 40 years, lower esophageal sphincter pressure > 15 mmHg, a cardia width < 5 mm, and an esophageal barium column height > 1 cm 4 to 12 weeks post-dilation significantly correlated with symptom recurrence, whereas achalasia subtypes did not significantly correlate with the treatment results.

CONCLUSION

Pneumatic dilation in achalasia is an effective therapy in the short term, but its effect wanes in the very long term. Young age at presentation, a high lower esophageal sphincter pressure, a narrow cardia, and an esophageal barium column of > 1 cm after PD are predictive factors for the need of repeated treatment.

[The revised version of standard terminology in gastroenterological endoscopy - result of a consensus project of the german society for gastroenterology, digestive and metabolic diseases]

A uniform and comprehensive terminology is essential in the correct documentation of diagnostic or therapeutic endoscopic procedure. In the German-speaking world, the standard terminology available so far is based on a previous version published in 1999. Therefore, the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) has undergone a comprehensive revision and re-structuring of the terminology. This appeared mandatory due to various changes, new diagnoses and new endoscopic procedures. The suggestions drawn up by individual working groups were approved by consensus and are now available as an online document (https://doi.org/10.1055/s-0043-121167) for modifying current software systems. In order to ensure an up-to-date documentation in the future, it was decided that annual updates will be performed by the DGVS to check respective software packages for modifications and new contents.

Clinical value of the Integrated Pulmonary Index® during sedation for interventional upper GI-endoscopy: A randomized, prospective tri-center study

BACKGROUND AND STUDY AIMS

The Integrated Pulmonary Index^® (IPI) is a mathematically-determined factor based on parameters of capnography and pulse oximetry, which should enable sensitive detection of impaired respiratory function. Aim was to investigate whether an additional measurement of the IPI during sedation for interventional endoscopy, compared to standard monitoring alone, allows a reduction of sedation-related respiratory depression.

PATIENTS AND METHODS

170 patients with standard monitoring randomly underwent either a blinded recording of capnography (control group, n=87) or capnography, including automated IPI calculation (IPI group, n=83), during deep sedation with midazolam and propofol. The primary endpoint was the maximum decrease of oxygen saturation from the baseline level before sedation. Secondary endpoints: incidence of hypoxemia (SaO₂<90%), other sedation-related complications (apnea rate, bradycardia, hypotension), patient cooperation and satisfaction (VAS).

RESULTS

Mean propofol dose in the IPI group (245±61mg) was comparable to the control group (225±47mg). The average drop of the oxygen saturation in the IPI group (6.5±4.1%) was nearly identical to that of the control group (7.1±4.6%, p=0.44). Apnea episodes >15s was found in 46 patients of the control and 31 of the IPI group (p<0.05). Frequency of occurrence of a drop in pO₂-saturation <90%, bradycardia <50/min or a drop of systolic pressure <90mmHg were not significantly different in both groups. Mechanical ventilation was not required in any case. Patient cooperation and satisfaction were assessed similar in both groups.

CONCLUSION

A clinically appealing advantage of IPI-assessment during deep sedation with midazolam and propofol for interventional endoscopy could not be documented. However, IPI registration was more effective in reducing the incidence of apnea episodes.

Capnographic monitoring of midazolam and propofol sedation during ERCP: a randomized controlled study (EndoBreath Study)

BACKGROUND AND STUDY AIMS

This was to determine whether intervention based on additional capnographic monitoring reduces the incidence of hypoxemia during midazolam and propofol sedation for endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients (American Society of Anesthesiologists [ASA] I – IV) scheduled for ERCP under midazolam and propofol sedation were randomly assigned to a control arm with standard monitoring or an interventional arm with additional capnographic monitoring. In both arms detection of apnea prompted withholding of propofol administration, stimulation of the patient, insertion of a nasopharyngeal tube, or further measures. The primary study end point was incidence of hypoxemia (oxygen saturation [Sao 2] below 90 %); secondary end points included occurrences of severe hypoxemia (Sao 2 ≤ 85 %), bradycardia, and hypotension, and sedation quality (patient cooperation and satisfaction).

RESULTS

242 patients were enrolled at three German endoscopy centers. Intention-to-treat analysis revealed no significant reduction in hypoxemia incidence in the capnography arm compared with the standard arm (38.0 % vs. 44.4 %, P = 0.314). Apnea was more frequently detected in the capnography arm (64.5 % vs. 6.0 %, P < 0.001). There were no differences regarding rates of bradycardia and hypotension. Per-protocol analysis showed lower incidence of hypoxemia in the capnography arm compared with the standard arm (31.5 % vs. 44.8 %, P = 0.048). There was one death related to sedation in the standard arm. Sedation quality was similar in the two groups.

CONCLUSION

Intention-to-treat analysis showed hypoxemia incidence was not significantly lower in the additional capnography arm compared with standard monitoring. Additional capnographic monitoring of ventilatory activity resulted in improved detection of apnea.

Prospective evaluation of the routine use of a nasopharyngeal airway (Wendl Tube) during endoscopic propofol-based sedation

BACKGROUND/AIMS

Insertion of a nasopharyngeal airway (NPA) during endoscopic sedation is only recommended in the event of respiratory problems. We evaluated the safety and efficacy of routine insertion of an NPA during sedation in gastrointestinal (GI) endoscopy.

METHODS

Between July 2009 and April 2012, patients with colonoscopy or expected longer-lasting or therapeutic upper GI endoscopy were pseudo-randomized in a weekly alternating fashion to perform sedation (midazolam in combination with propofol) with or without NPA insertion. The primary outcome measure was respiratory depression (oxygen saturation <90%). Secondary measures included hypotension (systolic blood pressure <90 mm Hg), bradycardia (heart rate <40 beats/min) or nasopharyngeal damage after NPA insertion.

RESULTS

216 (106 females, mean age 60.7 ± 9.65 years) were enrolled. Colonoscopy was performed in 131 patients and upper endoscopy in 85 patients. In 105 patients an NPA was used (intervention group). Five (4.7%) of those patients showed minor nasopharyngeal injury. Respiratory depression (13.5 vs. 1.9%, p = 0.002) and hypotension (11 vs. 5%, p = 0.09) occurred more frequently in the control than in the intervention group.

CONCLUSION

The routine placement of an NPA can reduce the frequency of hypoxemic events during endoscopic sedation with minor risks for nasopharyngeal injury.

Endoscopic sedation and monitoring practice in Germany: re-evaluation from the first nationwide survey 3 years after the implementation of an evidence and consent based national guideline

BACKGROUND AND STUDY AIMS

The use of sedation (e. g., of short-acting propofol) for gastrointestinal endoscopy has shown an upward trend in the USA and Europe over the last decade. To improve patient's safety different nationwide guidelines have been developed. This survey aimed at providing nationwide re-evaluated data 3 years after the implementation of consent- and evidence-based national guideline on sedation for gastrointestinal endoscopy.

METHODS

A 24-item survey regarding current practices of endoscopy, sedation and monitoring in gastrointestinal endoscopy was sent to 4 405 members of the German Society of Digestive and Metabolic Diseases (DGVS).

RESULTS

A total of 741/4405 (17 %) questionnaires were returned. Compared to 2007 we documented a further increase of the use of sedation during the performance of esophagogastro-duodenoscopies (EGDs) (82 vs. 74 % in 2007) and colonoscopies (91 vs. 87 % in 2007), accompanied with an increased rate of using propofol as a sedative agent in 97 vs. 74 % of the cases in 2007. In contrast the use of midazolam substantially decreased to 69 % versus 82 % in 2007. Most commonly used sedation regimens are still propofol ± benzodiazepines (43 vs. 38 % in 2007), while a combination of midazolam ± opioid decreased to 15 % versus 35 % in 2007. Unchanged to data from 2007, patients were routinely monitored by pulse oximetry (99 %). Routine use of an automated blood pressure monitoring increased to 40 % (versus 29 % in 2007) and the use of electrocardiography monitoring nearly doubled to 24 vs. 13 % in 2007. Supplemental oxygen is nowadays routinely administered in 64 % compared to 34 % of the cases in 2007. Regarding the administration of sedation we observed a profound increase of nurse-administered propofol sedation (NAPS; 73 % in 2011, 39 % in 2007) with a decrease of endoscopist-directed propofol sedation (29 % in 2011 vs. 59 % in 2007). However, monitored anaesthesia care was still only rarely used in Germany (2 %).

CONCLUSION

After the implementation of the first national sedation guideline the use of propofol has become the most popular sedation regime in Germany, mainly administered as NAPS by trained nurses as a standard procedure. Automated blood pressure measurements and ECG recording were more often implemented in the monitoring practice and also the routine use of supplemental oxygen has been clearly improved.

Endoscopic approach to achalasia

Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.

Magnetic resonance cholangiopancreatography (MRCP) for suspected bilio-pancreatic disease: should the endoscopist take a second look?

INTRODUCTION

MRCP enables a planar ductography of the pancreatobiliary system, which for diagnostic purposes may render ERCP unnecessary. However, the interpretation of MRCP findings is primarily performed by radiologists, and it is unclear whether additional interpretation of the MRCP results by the endoscopist alters clinical management.

PATIENTS AND METHODS

One-hundred and fifty-five consecutive patients, who were referred for further endoscopic procedures (EUS/ERCP) based on MRCP findings (performed within 4 weeks prior to admittance; a written radiological report as well as the digital images were available) were enrolled. Before the endoscopic examinations were done, the MRCP images were re-evaluated by an experienced endoscopist who was in charge of the further endoscopic management. The interpretations of the MRCP images by the radiologist and the endoscopist were then compared with the final diagnosis after the further endoscopic evaluation. Additionally, the recommendations made by the endoscopist for further patient management before and after MRCP image analysis were evaluated.

RESULTS

The MRCP image quality was judged sufficient by the endoscopist in the majority of the cases (80 %).The diagnostic accuracy of the MRCP findings was 73 % based on the interpretation by the radiologist and 86 % from the interpretation of the endoscopist. In 14 patients the endoscopist scheduled an EUS instead of an ERCP after he had viewed the MRCP images. Overall, the endoscopic work-flow was modified by the additional interpretation of the MRCP by the endoscopist in 25/155 (16 %) of the cases.

LIMITATIONS

This is a non-randomized, unblinded single-observer assessment.

CONCLUSION

MRCP images should be additionally interpreted by an endoscopist before further endoscopic procedures are scheduled.

Miniprobe endoscopic ultrasound accurately stages esophageal cancer and guides therapeutic decisions in the era of neoadjuvant therapy: results of a multicenter cohort analysis

BACKGROUND

Despite recent advances in imaging techniques, adequate classification of esophageal lesions is still challenging. Accurate staging of tumors of the esophagus is a precondition for targeted therapy. In this retrospective, multicenter study, we report the role of high-frequency endoscopic ultrasound (EUS) catheter probes in pretherapeutic staging of esophageal neoplasms and thus guiding treatment decisions.

METHODS

A total of 143 patients (mean age of 63.8 ± 10.7 years) with esophageal carcinoma were recruited from five German centers (Münster, Oldenburg, Hannover, Wiesbaden, and Lüneburg). Tumor type was adenocarcinoma in 112 (78 %) cases and squamous cell carcinoma in 31 (22 %). Tumor localization was as follows: proximal 3, mid esophagus 7, and distal third 133. Histological correlation either through EMR or surgery was available. In all patients, pretherapeutic uT and uN classifications were compared to pT/pN classification obtained from surgically (esophagectomy, n = 93) or endoscopically (EMR, n = 50) resected tissue.

RESULTS

Overall, accuracy of uT classification was 60 % and of uN classification was 74 %. Sensitivity, specificity, and accuracy rates for local tumor extension were as follows (%): T1: 68/97/83; T2: 39/84/75; T3: 72/81/79; T4: 13/97/93; T1/2: 73/81/75; T3/4: 78/82/81. Relating to positive lymph node detection, sensitivity and specificity were 76 and 71 %, respectively.

CONCLUSIONS

Miniprobe EUS is an established method for the staging of esophageal tumors. Our large multicenter cohort shows a solid accuracy of miniprobe EUS with respect to differentiating locally advanced from limited cancer and assisting to determine the treatment regimen in the era of neoadjuvant therapy; consequently, 78 % of patients would have been assigned to the adequate therapeutic regimen, whereas 11 % of patients would have been overtreated and 11 % undertreated.

Endoscopic findings in patients with Schatzki rings: Evidence for an association with eosinophilic esophagitis

AIM: To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE).

METHODS: We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.

RESULTS: A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies.

CONCLUSION: A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.

Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial

INTRODUCTION

Beside the traditional, intermittent bolus application of propofol, continuous propofol infusion via infusion pump is an alternative procedure for deep sedation during long-lasting interventional endoscopy. However, up to now, there are no randomized comparisons for gastrointestinal endoscopy.

METHODS

One hundred patients (ERCP: n = 60, EUS: n = 40) were randomly assigned to receive intermittent bolus application ("bolus group") or continuous infusion ("perfusor group") of propofol sedation after induction with 3 mg midazolam for deep sedation. Patients in the bolus group received an initial propofol dose according to body weight (bw <70 kg: 40 mg; bw ≥ 70 kg 60 mg). In the perfusor group, bw-adapted, continuous propofol infusion (6 mg/kg) via the Injectomat 2000 MC (Fresenius-Kabi) was administered after an initial bolus of 1 mg/kg. Vital signs, dose of propofol, patient cooperation (VAS 1-10), sedation depth, and the recovery time as well as the quality of recovery were evaluated.

RESULTS

Total propofol dose in the bolus group 305 ± 155 mg (100-570 mg) and in the perfusor group 343 ± 123 mg (126-590 mg, p = 0.5) were comparable. Oxygen saturation below 90% was seen in four patients of each group, with no need for assisted ventilation. Arterial blood pressure <90 mmHg was documented in two patients in the bolus group and seven patients in the perfusor group (p = 0.16). Patients' cooperation was rated as good in both groups (bolus group, 9.1 ± 0.9; perfusor group, 8.9 ± 1; p = 0.17). Recovery time was significantly shorter in the bolus group compared with the perfusor group (19 ± 5 versus 23 ± 6 min, p < 0.001) whereas the quality of recovery was nearly identical in both groups.

CONCLUSION

Both sedation regimens allow nearly identical good controllability of propofol sedation. However, recovery time was significantly slower and hypotension was tended to occur more often in the perfusor group.

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.

Extracorporeal shock wave lithotripsy with a transportable mini-lithotripter and subsequent endoscopic treatment improves clinical outcome in obstructive calcific chronic pancreatitis

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) of pancreatic duct stones followed by ERCP with mechanical clearance of the pancreatic duct and subsequent stenting is an established treatment option for chronic calcific pancreatitis.

OBJECTIVE

To test the efficacy of a modified transportable mini-lithotripter for ESWL of pancreatic duct stones.

DESIGN

Prospective single-center study.

SETTING

University hospital.

PATIENTS

This study involved 32 patients with obstructive chronic calcific pancreatitis and pain in whom previous endoscopic stone removal and pancreatic duct decompression had failed.

INTERVENTIONS

ESWL followed by ERCP for stone clearance of the pancreatic duct and mechanical removal of stones or stenting.

MAIN OUTCOME MEASUREMENTS

Endoscopic duct clearance and/or stent insertion, pain and quality-of-life scores.

RESULTS

A median of 4 ESWL sessions (interquartile range 2.75-8.5) with a median of 6800 shock waves (4225-15,425) were required. Pain relief after ESWL only was noted in 24 patients (75.0%), whereas no change in the intensity of pain was reported by 7 patients (21.9%), and pain was worse in 1 patient. All patients underwent ERCP and stent placement, resulting in complete resolution of pain in 17 patients (53.1%) and pain improvement in 28 patients (87.5%). The quality-of-life score was significantly improved after ESWL and endoscopic clearance or stenting in all patients.

LIMITATIONS

Uncontrolled study.

CONCLUSIONS

ESWL with the mini-lithotripter results in fragmentation of pancreatic duct calculi. ESWL in conjunction with endoscopic clearance of the pancreatic duct and stenting is associated with significant improvement in clinical outcome and quality of life in patients with obstructive calcific chronic pancreatitis.

Long-term results (≥ 10 years) of endoscopic therapy for sphincter of Oddi dysfunction in patients with acute recurrent pancreatitis

BACKGROUND AND STUDY AIMS

Sphincter of Oddi dysfunction (SOD) is one important cause of idiopathic acute-recurrent pancreatitis (ARP). Several trials have documented complete remission from ARP after endoscopic sphincterotomy during a 2-3-year follow-up. Data with longer follow-up, however, are not available.

PATIENTS AND METHODS

Between 1995 and 1998, endoscopic sphincterotomy was performed in 37 patients with manometrically documented SOD and ARP. Afterwards, all patients were prospectively re-evaluated over a period of at least 2 years. In 2008, all patients and their primary physicians were contacted and the patients were interviewed using a structured questionnaire. If a case or situation was unclear, the patients were clinically re-evaluated at our hospital.

RESULTS

During the initial prospective 2-year follow-up, relapsing pancreatitis was documented in 5/37 patients (14%). At this point, dual endoscopic sphincterotomy was performed in four patients, and one patient underwent surgical pancreatico-jejunostomy. On retrospective re-evaluation (total follow-up, 11.5±1.6 years) at least one episode of recurrent pancreatitis was found among 19/37 patients (51%). The mean number of relapses that occurred during long-term follow-up (0.7±0.7; range, 0-2) was lower than that recorded at the time of patient enrollment (2.5±0.5; range, 2-4). The recurrence rate did not differ with respect to the patient's first clinical presentation, their demographic data or initial manometric findings. However, relapsing pancreatitis was documented more often in patients who, in the past, had undergone either biliary or pancreatic endoscopic sphincterotomy (12/13 patients) than among those who had undergone dual endoscopic sphincterotomy first (7/24 patients; P<0.05). The median interval for relapsing pancreatitis was 3.5 years (range, 3-84 months).

CONCLUSIONS

Follow-up after endoscopic therapy for SOD in patients with ARP should be considered for at least 5 years. For endoscopic treatment, dual endoscopic sphincterotomy may be preferred, although this will not completely prevent recurrence of pancreatitis. Endoscopic therapy nonetheless helped to decrease the frequency of relapse.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

Propofol sedation in gastrointestinal endoscopy: a gastroenterologist's perspective

The present article describes the recommendations regarding the use of propofol by non-anesthesiologists from published guidelines. Furthermore, safety and efficacy data regarding the use of propofol in the hands of gastroenterologists are also reviewed. Although there are no studies comparing the safety and efficacy of propofol administration by anesthesiologists versus non-anesthesiologists for sedation during endoscopy, there is strong evidence that propofol administration by non-anesthesiologists is safe and efficacious for the majority of patients undergoing routine endoscopic procedures.

Extended monitoring of the sedated patient: bispectral index, Narcotrend and automated responsiveness monitor

It has been demonstrated that a processed EEG derivative may reflect the patient's level of consciousness during endoscopic sedation. However, to date a clinical benefit of EEG monitoring with respect to relevant safety parameters in routine gastrointestinal endoscopy has not been demonstrated. During long-lasting procedures (e.g. ERCP, ESD) a propofol-sparing effect has been shown, but a benefit regarding patient safety could not be documented. The use of an automated responsiveness monitor may help to achieve and to maintain the level of conscious sedation with propofol, but its precise role in endoscopic sedation is undefined.

Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study

OBJECTIVE

Midazolam sedation for upper gastrointestinal (GI) endoscopy exacerbates minimal hepatic encephalopathy (HE) in patients with liver cirrhosis, therefore an alternative drug regimen for these patients is warranted. The aim of this randomized, controlled study was to assess whether the use of the short-acting propofol as a sedative for GI endoscopy could prevent the exacerbation of minimal HE in patients with liver cirrhosis.

MATERIAL AND METHODS

The study comprised patients with liver cirrhosis without clinical HE who had undergone upper GI endoscopy for therapeutic purposes (intended variceal band ligation). Sixty patients were randomly assigned into two groups to receive propofol (n=40) or midazolam (n=20) for upper GI endoscopy. The study groups were matched for age, gender and Child-Pugh score. All patients completed number connecting tests (NCTs), as well as a porto-systemic encephalopathy (PSE) syndrome test before and at 2 h after completion of the endoscopic procedure. Time needed to fulfill the tests was documented. Baseline results of the psychomotor test batteries were compared with the post-interventional evaluations. Data were also compared with the results of a healthy control group (n=20) that did not undergo endoscopic sedation. Recovery time and quality (score system) were evaluated.

RESULTS

The differences in the NCT times before and after sedation (median delta NCT, midazolam group, 11 s (95% CI, -1.2 to 16.1 s) versus the propofol group, -9.5 s (95% CI, -15.7 to -4.6 s), p=0.002) and in the PSE scores (median delta PSE, midazolam group, -1 (95% CI, -1.5 to 0.2) versus the propofol group, 1 (95% CI, 0.5 to 1.5), p=0.0009) differed significantly between the two groups. In addition, the recovery time and quality in patients receiving propofol were significantly improved compared with in the midazolam group (7.8+/-2.9 min versus 18.4+/-6.7 min, 6.1+/-1.1 versus 8.2+/-1.3, both p<0.001).

CONCLUSIONS

The study demonstrates that propofol sedation for upper GI endoscopy does not cause acute deterioration of minimal hepatic encephalopathy and is associated with improved recovery in patients with liver cirrhosis. Propofol should be recommended for these patients as an alternative to midazolam.

Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey

BACKGROUND AND AIMS

The use of sedation (e. g., of short-acting propofol) for gastrointestinal endoscopy has shown an upward trend in the United States and Europe over the last decade. This survey aimed at providing nationwide data on the current practice of endoscopic sedation and monitoring in Germany.

METHODS

A 21-item survey regarding current practices of endoscopy, sedation and monitoring in gastrointestinal endoscopy was sent to 3 802 members of the German Society of Digestive and Metabolic Diseases (DGVS).

RESULTS

A total of 1 061 / 3 802 (28%) questionnaires were returned. The respondents performed an average of 28 esophagogastro-duodenoscopies (EGDs) and 25 colonoscopies per week. Endoscopic procedures were staged in a hospital setting (60%) more often than in private practices (40%). The majority of the EGDs (74%) and colonoscopies (87%) were carried out under sedation, however, this fact may be influenced by a recall bias. The most frequently used agents for sedation were midazolam in 82% and propofol in 74% of the cases. The most common sedation regimens applied were propofol plus benzodiazepines (38%) and benzodiazepines with an opioid (35%). Patients were routinely monitored by pulse oximetry (97%), automated blood pressure readings (29%) and/or electrocardiography (13%). Supplemental oxygen was routinely administered in 34% of them. Endoscopists' satisfaction with sedation was greater among those using propofol than in the group applying benzodiazepines (visual analogue scale, 8.8 +/- 0.9 vs. 8.2 +/- 1.3, p < 0.0001).

CONCLUSION

Besides the common administration of short-acting benzodiazepines, sedation with propofol is also gaining ground in Germany; it is applied mainly in low doses (up to 150 mg). German endoscopists are highly satisfied with these sedation regimens, with propofol significantly leading the score. Patient monitoring predominantly follows currently prevailing guidelines.

Endoscopist-directed administration of propofol: a worldwide safety experience

BACKGROUND & AIMS

Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation.

METHODS

We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death.

RESULTS

A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million.

CONCLUSIONS

EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study)

BACKGROUND

As with endoscopic transmural drainage of peripancreatic fluid collections, the same transluminal access can be expanded to introduce an endoscope through the gastrointestinal wall into the retroperitoneum and remove infected pancreatic necroses under direct visual control. This study reports the first large series with long-term follow-up.

METHODS

Data for all patients undergoing transluminal endoscopic removal of (peri)pancreatic necroses between 1999 and 2005 in six different centres were collected retrospectively, and the patients were followed up prospectively until 2008. The initial patient and treatment outcome data were recorded, as were long-term results.

RESULTS

Ninety-three patients (63 men, 30 women; mean age 57 years) underwent a mean of six interventions starting at a mean of 43 days after an attack of severe acute pancreatitis. After establishment of transluminal access to the necrotic cavity and subsequent endoscopic necrosectomy, initial clinical success was obtained in 80% of the patients, with a 26% complication and a 7.5% mortality rate at 30 days. After a mean follow-up period of 43 months, 84% of the initially successfully treated patients had sustained clinical improvement, with 10% receiving further endoscopic and 4% receiving surgical treatment for recurrent cavities; 16% suffered recurrent pancreatitis.

CONCLUSIONS

Direct transluminal endoscopic removal of pancreatic necroses is associated with good long-term maintenance of the high initial efficacy; complications can occur, with an associated mortality of around 7.5%. Further studies are necessary in order to optimise endotherapy and define its role in relation to surgery in the clinical management of such patients.

[Early Barrett's carcinoma/high grade intraepithelial neoplasia (HG-IEN): pro endoscopic treatment--pro surgical treatment]

Who may treat early Barrett's carcinoma of the oesophagus? The incidence of adenocarcinoma of the oesophagus developing within Barrett's mucosa has substantially risen in the past few years. Furthermore, treatment of preneoplastic lesions or early carcinoma is controversial. From an endoscopist's point of view high-grade intraepithelial neoplasia (HG-IEN) should be resected endoscopically rather than destroyed endoscopically while early Barrett's carcinoma should undergo endoscopic staging resection. Surgical resection is rarely necessary because lymph node metastases are rare and there is some morbidity and mortality associated with the procedure. However, surgeons argue that complete surgical resection is required because no imaging technique reveals the exact extent of the lesion and, ultimately, the degree of infiltration can only be determined within the resected specimen. Also, only surgical procedures may remove all potentially involved regional lymph nodes. Furthermore, only within surgical resections we can eliminate all pre-existing Barrett's mucosa easily while endoscopic clearance of Barrett's mucosa is difficult and requires multiple sessions. The Merendino-Siewert procedure may be an option with very low morbidity and mortality. It is worthy of note that new endoscopic resection procedures have not been studied in a controlled fashion against conventional surgical procedures. Therefore, patients with HG-IEN or early Barrett's carcinoma of the esophagus should be recruited into controlled studies and be treated in specialised high-volume centres.

Capsule endoscopy interpretation by an endoscopy nurse - a comparative trial

BACKGROUND

Capsule endoscopy is a common, pain-free diagnostic procedure for the small bowel. However, interpretation of the whole video recording is a time-consuming and costly procedure that can take up to 2 hours. The aim of the present study is two-fold: first to study the accuracy of capsule endoscopy analysis between a trained endoscopy nurse and a physician and secondly to determine if pre-evaluation by nursing staff might be time-effective for capsule reading. This study is especially important given the increasing financial pressure on current health-care systems.

METHODS

A long-standing experienced endoscopy nurse, who was trained to read capsule endoscopy, and a physician, both blinded to the patient diagnosis and the other clinical findings reviewed 48 consecutive capsule endoscopy videos. The analyses of both the nurse and the physician were re-evaluated by an independent doctor regarding the agreement of the marked findings.

RESULTS

Total time to read capsule endoscopy was significantly longer for the nurse's interpretation (63 +/- 26 min) as compared to the physician's interpretation (54 +/- 18 min, p < 0.01). The endoscopy nurse marked 236 thumbnails, whereas the doctor only marked 132 thumbnails. The nurse overlooked 4 of 64 relevant lesions (6 %), which had been detected by the physician. These overlooked lesions were not single important lesions, they were overlooked only in patients with multiple angiectasias of the small intestine, and thus the misdiagnosis was without clinical relevance. The physician overlooked 6 of 68 lesions detected by the nurse (9 %), also in patients with multiple angiodysplastic lesions and therefore without clinical relevance. On post-hoc analysis of the capsule video recordings the time needed by the physician to interpret the thumbnails marked by the nurse was 10 +/- 12 min. While there was no difference with respect to the estimated gastric emptying time (nurse 27 +/- 13 min vs. physician 28 +/- 14 min, n. s.), the estimated time of capsule passage through the ileocaecal valve was longer when interpreted by the endoscopy nurse (nurse 347 +/- 89 min vs. physician 326 +/- 74 min, n. s.). Nevertheless, the total cost for capsule pre-evaluation by the nurse was lower (13.23 euro vs. physician 17.82 euro).

CONCLUSION

The endoscopy nurse detected 94 % of the significant lesions seen by the physician and no clinically relevant findings were overlooked. A pre-evaluation of the capsule video by trained staff is an accurate method and might be time effective.

Catheter probe extraductal ultrasonography vs. conventional endoscopic ultrasonography for detection of bile duct stones

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) has been established as a valuable diagnostic tool for the detection of bile duct stones (BDS). The recently introduced extraductal endoscopic ultrasonography (EDUS) using miniprobes has the advantage that it can be performed with a duodenoscope, and if therapeutic interventions become necessary, there is no need to change the scope.

PATIENTS AND METHODS

Consecutive patients with acute biliary pain and a dilated bile duct and/or elevated liver function tests, in whom the origin of biliary obstruction could not be identified by US and CT, were enrolled. The patients were investigated with a linear-array echoendoscope, and an additional transduodenal EDUS examination was performed with a 12-MHz miniprobe via the instrumentation channel of the echoendoscope. The presence or absence of BDS was afterwards evaluated by endoscopic retrograde cholangiopancreatography (ERCP)/sphincterotomy (EST) and by instrumental bile duct exploration (in the case of a positive EUS/EDUS finding), or by magnetic resonance cholangiopancreatography (MRCP) and ERCP with additional clinical follow-up (in the case of negative findings on EUS/EDUS).

RESULTS

One hundred and fifty-five patients (55 +/- 12 years old, 98 female) were enrolled. In six cases, the distal bile duct could not be successfully visualized by EDUS, whereas with EUS visualization failed in only one patient ( P = 0.13). Choledocholithiasis was proven in 75 cases (48 %). The diagnostic accuracy of EUS for the detection of BDS (sensitivity 92 %, specificity 100 %, PPV 1.0, NPV 0.93, accuracy 95 %) was comparable to that of EDUS (sensitivity 90 %, specificity 98 %, PPV 0.99, NPV 0.93, accuracy 91 %, P = 0.17 vs. EUS).

CONCLUSIONS

In patients at intermediate risk of BDS it seems to be justified to perform EDUS instead of EUS, and to proceed with ERCP and EST immediately when findings are positive.

Sedation with propofol for interventional endoscopic procedures: a risk factor analysis

OBJECTIVE

Propofol sedation for mainly diagnostic endoscopic procedures has proved safe in recent trials, with no need for endotracheal intubation. However, there is evidence that cardiorespiratory side effects occur more frequently and that assisted ventilation may be necessary if propofol sedation is performed for interventional endoscopic procedures.

MATERIAL AND METHODS

Over a 6-year period, all adverse events (defined as premature termination of the procedure due to sedation-related events or either the need for assisted ventilation or admission to ICU) occurring during 9547 endoscopic interventions (UGI, n = 5.374, ERCP, n = 3.937, EUS, n=236) under propofol sedation were assessed.

RESULTS

A total of 135 adverse events (1.4%) were documented. Assisted ventilation was necessary in 40 patients (0.4%); 9 patients required endotracheal intubation (0.09%); 28 needed further monitoring on the ICU (0.3%); and 4 patients died, 3 potentially due to sedation-related side effects (mortality, 0.03%). Independent risk factors for sedation-related side effects were emergency endoscopic examinations and a total propofol dose >100 mg.

CONCLUSIONS

Interventional endoscopy under propofol sedation is not risk-free. Increased attention must be focused on close monitoring of vital parameters, particularly when undertaking long-lasting interventions and emergency procedures.

Solid state biliary manometry catheter: impact on diagnosis and post-study pancreatitis

Perfusion manometry of the sphincter of Oddi has been the standard for the investigation of patients with presumed sphincter of Oddi dysfunction (SOD). Microtransducer manometry (MTM) of the sphincter of Oddi represents an alternative to perfusion manometry. The technical success and reproducibility of MTM are as good as for perfusion manometry. Current data suggest that the upper limit for normal of basal sphincter of Oddi pressures measured with MTM lies at approximately 35 mm Hg. Pancreatitis risk after MTM in patients with SOD compares favorably with that after perfusion manometry. Low cost and ease of handling make MTM of the sphincter of Oddi an attractive alternative.

[A rare cause of dysphagia and bolus obstruction in adults]

HISTORY

An otherwise healthy 20-year-old man was admitted to our hospital with obstruction of the oesophagus by a bolus after eating a chicken meal. These symptoms continued over the past 12 years and required multiple interventions at different hospitals. There was no history of any other previous illness and both the physical examination and routine laboratory tests were unremarkable.

INVESTIGATIONS

Esophagogastroduodenoscopy (EGD) revealed segmental circular trachea-like constrictions of the esophagus and two stenoses at 35 cm and 40 cm. Histopathology of several biopsies favored the diagnosis of eosinophilic esophagitis.

TREATMENT AND FURTHER COURSE

After initial balloon dilatation and dilatation with a Savary bougie the patient was put on systemic steroids and montelukast (a leukotriene receptor antagonist). The symptoms subsequently disappeared.

CONCLUSION

Eosinophilic esophagitis, a unique form of esophageal inflammatory disease, consists of dense eosinophilic infiltration of the epithelium and is associated with various macroscopic findings, such as the rare but striking circular trachea-like constrictions, nodules, plaques and other forms of constriction of the esophagus. Several lines of evidence favor an allergic cause. The leading symptom is recurrent dysphagia after solid foods, sometimes accompanied by heart-burn. Medical treatment consists of topical or systemic administration of steroids and/or montelukast. A history of chronic dysphagia after eating solid food, combined with endoscopic findings atypical for reflux disease is highly suspicious of eosinophilic esophagitis in the differential diagnosis of gastroesophageal reflux disease in adults.