Non-anesthesiologist administrated propofol (NAAP) during endoscopic submucosal dissection for elderly patients with early gastric cancer

Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review

Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.

Efficacy and safety of endoscopic submucosal dissection for gastric epithelial neoplasia in elderly patients aged 80 years and older

BACKGROUND

Endoscopic submucosal dissection (ESD) has been widely used in gastric tumor as a minimally invasive treatment. The efficacy and safety of ESD is still unclear in the elderly who have high frequency comorbidities. The aim of this study is to evaluate the efficacy and safety of ESD for gastric epithelial neoplasia in patients aged 80 years and older.

METHODS

Between March 2013 and July 2017, a total of 438 gastric epithelial neoplasia patients treated with ESD were analyzed. Clinical outcomes including en bloc and complete resection rates, adverse events (AE) related procedure and sedation were compared between the elderly group and the non-elderly group.

RESULTS

Sex, Body Mass Index, medication history and American Society of Anesthesiologists physical status did not differ between the two groups. Tumor characteristics except size of resected specimen (elderly vs. non-elderly; 36.5 ± 10.5 vs. 32.3 ± 8.7 mm, p < 0.011) did not differ. There were no significant differences in AE-related sedation. En bloc resection (elderly vs. non-elderly; 100% vs. 98.3%, p = 0.454), and complete resection rate (elderly vs. non-elderly; 93.8% vs. 96.3%, p = 0.471) did not differ significantly between the two groups. Procedure time, hospital stay, AE-related procedure and delayed bleeding were also similar between the two groups. However, procedure time of preventive hemostasis (elderly vs. non-elderly; 10.4 ± 7.7 vs. 7.4 ± 5.2 min, p = 0.040) was significantly higher in the elderly group.

CONCLUSIONS

ESD for gastric epithelial neoplasia is effective and safe in elderly patients ≥ 80 years as in non-elderly patients.

Safety and Efficacy of Nonanesthesiologist-Administrated Propofol during Endoscopic Submucosal Dissection of Gastric Epithelial Tumors

Objective

There is no consensus regarding administration of propofol for performing endoscopic submucosal dissection (ESD) in patients with comorbidities. The aim of this study was to evaluate the safety and efficacy of propofol-induced sedation administered by nonanesthesiologists during ESD of gastric cancer in patients with comorbidities classified according to the American Society of Anesthesiologists (ASA) physical status.

Methods

Five hundred and twenty-two patients who underwent ESD for gastric epithelial tumors under sedation by nonanesthesiologist-administrated propofol between April 2011 and October 2017 at Dokkyo Medical University Hospital were enrolled in this study. The patients were divided into 3 groups according to the ASA physical status classification. Hypotension, desaturation, and bradycardia were evaluated as the adverse events associated with propofol. The safety of sedation by nonanesthesiologist-administrated propofol was measured as the primary outcome.

Results

The patients were classified according to the ASA physical status classification: 182 with no comorbidity (ASA 1), 273 with mild comorbidity (ASA 2), and 67 with severe comorbidity (ASA 3). The median age of the patients with ASA physical status of 2/3 was higher than the median age of those with ASA physical status of 1. There was no significant difference in tumor characteristics, total amount of propofol used, or ESD procedure time, among the 3 groups. Adverse events related to propofol in the 522 patients were as follows: hypotension (systolic blood pressure < 90 mmHg) in 113 patients (21.6%), respiratory depression (SpO₂ < 90%) in 265 patients (50.8%), and bradycardia (pulse rate < 50 bpm) in 39 patients (7.47%). There was no significant difference in the incidences of adverse events among the 3 groups during induction, maintenance, or recovery. No severe adverse event was reported. ASA 3 patients had a significantly longer mean length of hospital stay (8 days for ASA 1, 9 days for ASA 2, and 9 days for ASA 3, P = 0.003). However, the difference did not appear to be clinically significant.

Conclusions

Sedation by nonanesthesiologist-administrated propofol during ESD is safe and effective, even for at-risk patients according to the ASA physical status classification.

Comparison of sedation between the endoscopy room and operation room during endoscopic submucosal dissection for neoplasms in the upper gastrointestinal tract

BACKGROUND

The present study was performed to compare the safety of sedation during endoscopic submucosal dissection (ESD) in the endoscopy room versus operation room.

METHODS

In total, 297 patients with gastrointestinal tumors who underwent ESD from January 2011 to December 2016 were retrospectively reviewed. The patients were divided into two groups: those who underwent ESD in the endoscopy room without propofol (Group E) versus operation room with propofol (Group O). The patient, tumor, and procedure characteristics; adverse events; and treatment outcomes were compared between the two groups.

RESULTS

The patient and tumor characteristics, including age (73.6 ± 8.2 vs. 72.5 ± 9.1 years), comorbidities, and tumor size and histology, were not different between Groups E and O. The ESD procedure time was comparable between Groups E and O (105.4 ± 70.4 vs. 106.5 ± 64.4 min), and the anesthesia time was equivalent (138.3 ± 78.1 vs. 148.4 ± 68.8 min). There were no significant differences in adverse events between the two groups. During the ESD procedure, desaturation occurred significantly more often in Group E than O (12.9% vs. 4.0%, P = 0.021, odds ratio: 3.53, 95% CI: 1.17-14.4). The recovery time after ESD was significantly longer in Group E than O (180 (100-360) vs. 90 (0-180) min, P < 0.001).

CONCLUSIONS

A decreased desaturation rate and shorter recovery time after ESD were the advantages of sedation in the operation room with propofol compared with sedation in the endoscopy room. These findings warrant further exploration of the advantages of safe and effective ESD for upper gastrointestinal neoplasms in the operation room.

Updated evidence on endoscopic resection of early gastric cancer from Japan

BACKGROUND

Endoscopic resection for early gastric cancer (EGC) plays a central role in the treatment of EGC in Japan. However, there is still room for improvement, and it is necessary to summarize the recently obtained knowledge from Japan for further improvement.

METHODS

We conducted a PubMed search to select relevant articles in the 5 years until September 18, 2016, using the keywords "gastric cancer" and "endoscopic treatment," "endoscopic submucosal dissection," "endoscopic mucosal resection," or "polypectomy" and filtering article types as "clinical study" or "clinical trial."

RESULTS

Among the 329 articles selected automatically from the keywords "polypectomy" (1 article), "endoscopic mucosal resection" (29 articles), "endoscopic submucosal dissection" (77 articles), and "endoscopic treatment" (222 articles) in combination with "gastric cancer," 32 relevant articles from Japanese investigators were chosen. Seven articles were categorized into "equipment," 4 into "preparation and sedation," 17 into "complications and their prevention," and 4 into "therapeutic outcomes." Among them, CO₂ insufflation, propofol sedation, and how to prevent post-endoscopic submucosal dissection (ESD) ulcer bleeding and achieve post-ESD ulcer healing were intensively investigated. Long-term outcomes of endoscopic mucosal resection and ESD were also reported as favorable outcomes.

CONCLUSIONS

Endoscopic resection for EGC is still developing toward an ideal form, pursuing a more reliable, safer, and faster minimally invasive treatment.

Safety of Target-Controlled Propofol Infusion by Gastroenterologists in Patients Undergoing Endoscopic Resection

BACKGROUND

A target-controlled infusion (TCI) of a propofol system uses a pharmacokinetic model to achieve and maintain a selected target blood propofol concentration. The aim of this study was to assess whether the propofol TCI system could be safely used by gastroenterologists in patients undergoing endoscopic resection including endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) compared with a manually controlled infusion (MCI) system.

METHODS

A total of 431 patients undergoing therapeutic endoscopy (178 ESD and 253 EMR) were consecutively included from November 2011 to August 2014. The patients were divided into the MCI (271) and TCI (160) propofol infusion groups. We compared adverse event rates in MCI and TCI groups and assessed independent risk factors for adverse events.

RESULTS

The total sedation-related adverse event rate was 5.8 % (25/431). Most of the events were minor, and the rate of major events was 0.5 % (2/431). There was no significant difference in adverse event rate between the MCI and TCI groups [5.5 % (15/271) vs. 6.3 % (10/160); P = 0.759]. In univariate analysis, the propofol infusion time was significantly associated with adverse events (94.88 vs. 59.45 min, P = 0.017). In the multivariate analysis, there were no significant factors associated with adverse events. TCI was not an independent risk factor for adverse events despite the fact that the TCI had a longer duration of infusion and higher total infusion dose (95 % CI, 0.343-2.216; P = 0.773).

CONCLUSIONS

TCI of propofol by gastroenterologists may provide safe sedation in patients undergoing ESD and EMR under careful respiratory monitoring.

Propofol sedation with a target-controlled infusion pump and bispectral index monitoring system in elderly patients during a complex upper endoscopy procedure

BACKGROUND AND AIMS

Although the usefulness of propofol sedation during endoscopic submucosal dissection (ESD) for gastric neoplasms was reported previously, information is limited on its use in elderly patients. We investigated the safety and efficacy of propofol sedation with a target-controlled infusion (TCI) pump and bispectral index (BIS) monitoring system (TCI/BIS system) in elderly patients during gastric ESD.

METHODS

Included were 413 consecutive gastric ESD procedures involving 455 lesions (379 patients) performed in patients under propofol sedation with a TCI/BIS system between October 2009 and September 2013. Patients were divided into 3 groups: group A, age <70 years (n = 162); group B, age ≥70 and <80 years (n = 171); and group C, age ≥80 years (n = 80). We compared the propofol dose and adverse events (eg, hypotension and hypoxemia) during ESD.

RESULTS

Older groups required a lower target concentration of propofol (group A: median 2.1 μg/mL [interquartile range (IQR), 1.9-2.3]; group B: median 1.6 μg/mL [IQR, 1.3-1.8]; and group C: median 1.4 μg/mL [IQR, 1.2-1.6]; P < .0001). Hypotension tended to occur in the younger group, and hypoxemia occurred at a significantly higher rate in the older groups, although the number of cases was small. Low preoperative systolic blood pressure (≤125 mm Hg) was associated with hypotension (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.12-2.70; P = .013) and abnormal pulmonary function was associated with hypoxemia in groups B and C (OR, 4.54; 95% CI, 1.01-31.5; P = .048).

CONCLUSIONS

Elderly patients required lower doses of propofol with the TCI/BIS system than younger patients. Attention to hypoxemia is necessary in elderly patients, particularly patients with abnormal pulmonary function.

Clinical Outcomes and Complications of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms in the Elderly

The number of elderly people with superficial gastric neoplasms is increasing, but the clinical outcome of endoscopic submucosal dissection (ESD) for treating elderly people with superficial gastric neoplasms remains unclear. We aimed to compare the efficacy and safety of ESD for patients with early gastric cancer (EGC) and precancerous lesions in elderly (≥75 years of age) and nonelderly (<75 years of age) patients.From October 2005 to December 2014, 83 consecutive patients with EGC and precancerous lesions (86 lesions) who were treated using ESD in our hospital were retrospectively reviewed. There were 44 lesions in 42 elderly patients who were at least 75-years old. The following parameters were compared between the 2 groups: preexisting comorbidities, performance status (PS), lesion inclusion criteria, lesion characteristics, treatment outcomes, surgery time, duration of hospitalization, complications, and intraoperative hemodynamic changes.Elderly patients had significantly higher preexisting comorbidity rates (90.9% vs 59.5%, P = 0.001), expanded lesion criteria rates (43.2% vs 19.0%, P = 0.016), and lower best PS rates (38.6% vs 81.0%, P < 0.001) than nonelderly patients. Lesion characteristics were similar in the 2 groups. The elderly had higher intraoperative hypotension rates (47.7% vs 21.4%, P = 0.011) and oxygen desaturation rates (9.1% vs 0.0%, P = 0.045) than nonelderly patients. In addition, the elderly also had a longer surgery time (107.0 ± 51.4 vs 91.5 ± 66.2 minutes, P = 0.049) and duration of hospitalization (7.5 ± 3.8 vs 5.9 ± 2.0 days, P = 0.016) than nonelderly patients. There were no differences in the prevalence rates of en-bloc resection, complete resection, bleeding, perforation, pneumonia, or intraabdominal free air between the 2 groups.Although elderly patients who underwent ESD for superficial gastric neoplasms had an increasing risk of intraoperative hypotension and oxygen desaturation, all patients were treated appropriately without postoperative sequelae. ESD is a safe and feasible intervention for elderly patients who have more comorbidity, a worse PS and more expanded lesions.

Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde cholangiopancreatography

Background. The safety of non-anesthesiologist-administered propofol (NAAP) sedation in emergent endoscopic retrograde cholangiopancreatography (ERCP) has not been fully clarified. Thus, the aim of this study was to assess the safety of NAAP sedation in emergent ERCP. Materials and Methods. We retrospectively analyzed 182 consecutive patients who had obstructive jaundice and who underwent ERCP under NAAP sedation. The patients were divided into Group A (with mild acute cholangitis or without acute cholangitis) and Group B (moderate or severe acute cholangitis). And technical safety and adverse events were assessed. Results. The adverse events were hypoxia (31 cases), hypotension (26 cases), and bradycardia (2 cases). There was no significant difference in the rate of each adverse event of hypoxia and bradycardia in either group. Although the rate of transient hypotension associated in Group B was higher than that in Group A, it was immediately improved with conservative treatment. Moreover, there were no patients who showed delayed awakening, or who developed other complications. Conclusions. In conclusion, NAAP sedation is feasible even in emergent ERCP. Although some transient adverse events (e.g., hypotension) were observed, no serious adverse events occurred. Thus, propofol can be used in emergent ERCP but careful monitoring is mandatory.

A target-controlled infusion system with bispectral index monitoring of propofol sedation during endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Propofol administration via a target-controlled infusion system with bispectral index monitoring (BIS/TCI system) is expected to prevent complications from sedation during complex and long endoscopic procedures. We evaluated the feasibility of setting the BIS/TCI system for non-anesthesiologist administration of propofol (NAAP) during endoscopic submucosal dissection (ESD).

PATIENTS AND METHODS

From May 2009 to February 2013, 250 patients with esophagogastric neoplasms were treated with ESD using the BIS/TCI system with NAAP. In the TCI system, the initial target blood concentration of propofol was set at 1.2 μg/mL. The titration speed of propofol was adjusted according to the BIS score and the movement of the patient. The BIS target level ranged from moderate to deep sedation, at which a stable BIS score between 60 and 80 was obtained.

RESULTS

In 80.4 % of patients, it was possible to maintain stable sedation with a blood concentration of propofol of less than 1.6 µg/mL using TCI throughout the ESD procedure. The default setting for ideal blood concentration of propofol was 1.2 μg/mL, because the medians of the lower and upper bounds of blood concentration were 1.2 μg/mL (range 0.6 - 1.8 μg/mL) and 1.4 μg/mL (range 1.0 - 3.8 μg/mL), respectively. Although hypotension occurred in 27 patients (10.8 %), oxygen desaturation occurred in only nine patients (3.6 %), and severe desaturation in only two patients (0.8 %).

CONCLUSIONS

Using our settings, it is possible for a non-anesthesiologist to maintain stable sedation during a lengthy endoscopic procedure through propofol sedation with a BIS/TCI system.

The usage of overtube has a favorable effect on endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) may be very time consuming, and depending on the anesthesia, the contents of the stomach may reflux to the esophagus and cause the patient to aspirate. To prevent these situations, many practitioners suggest using an overtube, but no study has been done to evaluate the effect of the use of an overtube while performing the ESD procedure. Our aim was to investigate the effects of performing an upper gastrointestinal ESD with and without overtube.

METHODS

Records of patients who underwent ESD were evaluated for histopathological results, complications, speed of dissection, dosages of anesthetic medications, and number of suctions performed during the procedure. The patients were classified into two depending on whether an overtube was used or not.

RESULTS

There were a total of 58 patients on which 63 upper gastrointestinal ESD procedures were performed. Regarding age, gender, localization of the lesions, duration of the procedures, dosage of propofol, histopathological results, rate of complete resection, and rate of en-bloc resection, there was no difference between the two groups (p > 0,05). But the size of the lesions, the size of the resected specimen, and the speed of dissection were statistically different in two groups (p = 0.018, p < 0.001, p < 0.001, respectively).The need for suction during the procedure was much lower in the overtube group than those with no overtube (p < 0.001).

CONCLUSIONS

We conclude that using an overtube during an upper gastrointestinal ESD decreases the need for suction, favors the speed of dissection, and eases the comfort of the procedure.