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Li AA, Zhou MJ, Hwang JH. Understanding the Principles of Electrosurgery for Endoscopic Surgery and Third Space Endoscopy. Gastrointest Endosc Clin N Am 2023; 33:29-40. [PMID: 36375884 DOI: 10.1016/j.giec.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Electrosurgery is the application of high-frequency electrical alternating current to biologic tissue to cut, coagulate, desiccate, and/or fulgurate. Electrosurgery is commonly used in gastrointestinal endoscopy, with applications including biliary sphincterotomy, polypectomy, hemostasis, the ablation of lesions, and endoscopic surgery. Understanding electrosurgical principles is important in endoscopic surgery to achieve the desired therapeutic effect, optimize procedural outcomes, and minimize risks or adverse events. This article describes fundamental principles that apply to electrosurgical units, operator technique, and practical considerations for achieving desired tissue effects in endoscopic surgery; and provides practical guidance and safety considerations when using electrosurgical units in endoscopic surgery.
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Affiliation(s)
- Andrew A Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; 430 Broadway, Pavilion C-3rd Floor, GI Suite, Redwood City, CA 94063, USA
| | - Margaret J Zhou
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; 430 Broadway, Pavilion C-3rd Floor, GI Suite, Redwood City, CA 94063, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; 430 Broadway, Pavilion C-3rd Floor, GI Suite, Redwood City, CA 94063, USA.
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Bazerbachi F, White RM, Forbes N, Goudra B, Abu Dayyeh BK, Chandrasekhara V, Sweitzer B. Endo-anesthesia: a primer. Gastroenterol Rep (Oxf) 2022; 10:goac069. [PMID: 36381224 PMCID: PMC9664071 DOI: 10.1093/gastro/goac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.
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Affiliation(s)
- Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital , St Cloud, MN, USA
| | - Rodger M White
- Department of Anesthesia, Massachusetts General Hospital , Boston, MA, USA
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary , Calgary, Alberta, Canada
| | - Basavana Goudra
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania , Philadelphia, PA, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, MN, USA
| | | | - BobbieJean Sweitzer
- Systems Director, University of Virginia, Preoperative Medicine, InovaHealth , Falls Church, VA, USA
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Abstract
Exponential growth in endoscopy suite procedures due to technological advances requires teamwork between anesthesiologists, endoscopists, nursing teams, and technical and support staff. The current standard of care for moderate sedation includes a combination of anxiolytic drugs and analgesic drugs and sometimes are not adequate to ensure patient safety, efficiency, and comfort. The use of anesthesia services can improve safety, recovery, turnovers, and efficiency. The article discusses comprehensive preoperative evaluation, optimization of comorbidities, and intraoperative airway management strategies to deliver safe and efficient anesthesia, given the need to share the airway and allow the use of carbon dioxide in the gastrointestinal suite.
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Affiliation(s)
- Sekar S Bhavani
- Department of General Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Basem Abdelmalak
- Department of General Anesthesiology, Anesthesia for Bronchoscopic Surgery, Center for Sedation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Patel B, Shiani A, Rodriguez AC, Lipka S, Davis-Yadley AH, Nelson KK, Rabbanifard R, Kumar A, Brady PG. Outcomes in Patients with Left Ventricular Assist Devices, Pacemakers, and Implantable Cardioverter Defibrillators Undergoing Single Balloon Enteroscopy. South Med J 2019; 112:130-134. [PMID: 30708381 DOI: 10.14423/smj.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Obscure overt gastrointestinal bleeding can be challenging to evaluate in patients with electronic cardiac devices such as continuous flow left ventricular assist devices (LVADs), pacemakers (PPMs), and implantable cardioverter defibrillators (ICDs). Limited data exist on the utility and safety of single balloon enteroscopy (SBE) in patients with cardiac devices. We aimed to evaluate the safety, efficacy, diagnostic, and therapeutic outcomes of the aforementioned devices in patients undergoing SBE. METHODS A retrospective study was performed using the medical records of 57 patients undergoing SBE at our institution from 2010 to 2014. Patients were divided into two groups: those with cardiac devices and those without. Data on comorbidities, complications, findings, diagnostic, and therapeutic yield were compared. t Test and logistic regression assessed the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and standard deviation. For dichotomous data, the results were summarized as odds ratio and 95% confidence intervals. RESULTS The overall age in patients with cardiac devices was 67.89 ± 6.96 versus 66.03 ± 11.95 years in the control. The cardiac device group was composed of 42.1% women; the control comprised 21.1% women. There were 19 patients with cardiac devices; 8 (LVAD + ICD), 1 (LVAD + PPM + ICD), 2 (PPM + ICD), 6 (PPM), 2 (ICD); 38 patients were in the control group. Patients with cardiac devices were hospitalized more often than patients without devices; this finding was not statistically significant (odds ratio 1.826, 95% confidence interval 0.544-6.128, P = 0.389). Procedure times were longer in the cardiac device group, 65.16 ± 49.92 minutes, when compared with the control, 57.40 ± 20.42, but it also did not reach statistical significance (mean difference 7.758, 95% confidence interval -11.360 to 26.876, P = 0.049). There was no statistically significant difference in major or minor events between patients with cardiac devices and the control group. Diagnostic and therapeutic yield and rebleeding rates were similar across both groups. CONCLUSIONS Patients in the cardiac device group did not appear to be at any more significant risk than those without cardiac devices. Furthermore, diagnostic and therapeutic yield and rebleeding rates appear to be similar across both groups. Clinicians may perform SBE in these patients safely and effectively, with good overall outcomes.
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Affiliation(s)
- Brijesh Patel
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ashok Shiani
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Andrea C Rodriguez
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Seth Lipka
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ashley H Davis-Yadley
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Kirbylee K Nelson
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Roshanak Rabbanifard
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ambuj Kumar
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Patrick G Brady
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
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Haghjoo M, Akhondi B, Ansari-Ramandi M, Heidarali M, Kamali F. Safety and outcomes of noncardiac surgery in patients with cardiac implantable electronic devices. Res Cardiovasc Med 2019. [DOI: 10.4103/rcm.rcm_16_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Malagù M, Ferri A, Mancuso O, Trevisan F, Nardozza M, Bertini M. Implantable cardioverter defibrillator management: an update. Future Cardiol 2016; 12:673-688. [PMID: 27762625 DOI: 10.2217/fca-2016-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Implantable cardioverter defibrillator (ICD) is the cornerstone of primary and secondary prevention of sudden cardiac death. In 35 years of technologic improvement and clinical trials, there has been a continuous increase in implantation rate. Purpose of this review is to point out and discuss every aspect related to actual ICD management, investigating implantation procedure and predischarge care, office and remote monitoring follow-up, diagnostic evaluations, management of patients with suspected therapies or malfunctions, heart failure, surgery, radiotherapy and endoscopic procedures. Also, ICD backface such as infections and other complications will be discussed. Finally, we will focus on interesting future perspectives for this setting of patients.
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Affiliation(s)
- Michele Malagù
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
| | - Alessandra Ferri
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
| | - Ottavia Mancuso
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
| | - Filippo Trevisan
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
| | - Marianna Nardozza
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
| | - Matteo Bertini
- Department of Cardiology, University of Ferrara, S Anna Hospital, Ferrara, Italy
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Kim EY. Is It Safe to Perform Therapeutic Endoscopic Procedures in Patients with Implanted Electronic Cardiac Devices? Clin Endosc 2016; 49:104-5. [PMID: 27012289 PMCID: PMC4821511 DOI: 10.5946/ce.2016.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Baeg MK, Kim SW, Ko SH, Lee YB, Hwang S, Lee BW, Choi HJ, Park JM, Lee IS, Oh YS, Choi MG. Endoscopic Electrosurgery in Patients with Cardiac Implantable Electronic Devices. Clin Endosc 2016; 49:176-81. [PMID: 26867552 PMCID: PMC4821527 DOI: 10.5946/ce.2015.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/19/2015] [Accepted: 05/11/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS Patients with cardiac implantable electronic devices (CIEDs) undergoing endoscopic electrosurgery (EE) are at a risk of electromagnetic interference (EMI). We aimed to analyze the effects of EE in CIED patients. METHODS Patients with CIED who underwent EE procedures such as snare polypectomy, endoscopic submucosal dissection (ESD), and endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) were retrospectively analyzed. Postprocedural symptoms as well as demographic and outpatient follow-up data were reviewed through medical records. Electrical data, including preprocedural and postprocedural arrhythmia records, were reviewed through pacemaker interrogation, 24-hour Holter monitoring, or electrocardiogram. RESULTS Fifty-nine procedures in 49 patients were analyzed. Fifty procedures were performed in 43 patients with a pacemaker, and nine were performed in six patients with an implantable cardioverter-defibrillator. There were one gastric and 44 colon snare polypectomies, five gastric and one colon ESDs, and eight ERCPs with EST. Fifty-five cases of electrical follow-up were noted, with two postprocedural changes not caused by EE. Thirty-one pacemaker interrogations had procedure recordings, with two cases of asymptomatic tachycardia. All patients were asymptomatic with no adverse events. CONCLUSIONS Our study reports no adverse events from EE in patients with CIED, suggesting that this procedure is safe. However, because of the possibility of EMI, recommendations on EE should be followed.
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Affiliation(s)
- Myong Ki Baeg
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Woo Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun-Hye Ko
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Bum Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seawon Hwang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong-Woo Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Jin Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In-Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Electrosurgery allows both cutting and coagulation of tissue and is an essential tool for therapeutic endoscopy. Electrosurgery is also the most commonly used and misunderstood technology by all surgical and medical disciplines. In other words, everyone uses it, but few understand it! The aims of this article are to (1) present a useful review of the fundamentals of electrosurgery technology; (2) relate the fundamentals to commonly performed flexible endoscopy procedures; and (3) provide a review of the safe application of grounding pads, careful management of accessories, and special patient safety considerations.
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Ryan JJ, Butrous G, Maron BA. The heterogeneity of clinical practice patterns among an international cohort of pulmonary arterial hypertension experts. Pulm Circ 2015; 4:441-51. [PMID: 25621157 DOI: 10.1086/677357] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/16/2014] [Indexed: 11/03/2022] Open
Abstract
The extent to which pulmonary arterial hypertension (PAH) experts share common practice patterns that are in alignment with published expert consensus recommendations is unknown. Our objective was to characterize the clinical management strategies used by an international cohort of self-identified PAH experts. A 32-item questionnaire composed mainly of rank order or Likert scale questions was distributed via the Internet (August 5, 2013, through January 20, 2014) to four international pulmonary vascular disease organizations. The survey respondents (N = 105) were field experts reporting 11.6 ± 8.7 years of PAH experience. Likert scale responses (1 = disagree, 7 = agree) were 3.0-5.0, indicating a disparity in opinions, for 78% of questions. Respondent (dis)agreement scores were 4.4 ± 2.2 for use of expert recommendations to determine catheterization timing in PAH. For PAH patients without cardiogenic shock or known vasoreactivity status, the most and least preferred first-line therapies (1 = most preferred, 5 = least preferred) were phosphodiesterase type 5 inhibitors (PDE-Vi) and subcutaneous prostacyclin analogues, respectively (1.4 ± 0.8 vs. 4.0 ± 1.1; P < 0.05). Compared with US-practicing clinicians (N = 46), non-US-practicing clinicians (N = 57) favored collaboration between cardiology and pulmonary medicine for clinical decision making (1 = disagree, 7 = agree; 3.1 ± 2.2 vs. 4.8 ± 2.2; P < 0.0001) and PDE-Vi (6.5% vs. 22.4%) as first-line therapy for PAH patients with cardiogenic shock but were less likely to perform vasoreactivity testing in patients with lung disease-induced pulmonary hypertension (4.3 ± 2.1 vs. 2.2 ± 1.6; P < 0.0001). In conclusion, practice patterns among PAH experts diverge from consensus recommendations and differ by practice location, suggesting that opportunity may exist to improve care quality for this highly morbid cardiopulmonary disease.
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Affiliation(s)
- John J Ryan
- Division of Cardiology, University Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Ghazwan Butrous
- School of Pharmacy, University of Kent, Kent, United Kingdom
| | - Bradley A Maron
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; and Department of Cardiology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
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