Propofol-Based Sedation Versus General Anesthesia for Endoscopic Submucosal Dissection

Anesthesia choice and its potential impact on endoluminal functional lumen imaging probe measurements in esophageal motility disorders

BACKGROUND AND AIMS

The widespread use of peroral endoscopic myotomy (POEM) has revolutionized the management of esophageal motility disorders (EMDs). The introduction of an endoluminal functional lumen imaging probe (EndoFLIP, Medtronic, Dublin, Ireland) can serve as a complementary diagnostic tool to assess the mechanical properties (ie, pressure, diameter, distensibility, topography) of the esophagus. During EndoFLIP measurements, different anesthesia techniques may induce variable degrees of neuromuscular blockade, potentially affecting esophageal motility and altering the results of EndoFLIP metrics. The aim of this study was to compare the impact of using total intravenous anesthesia (TIVA) versus general anesthesia with inhalational anesthetics (GAIA) on diagnostic EndoFLIP measurements.

METHODS

This retrospective study included all adult patients (≥18 years) undergoing EndoFlip during the POEM procedure at our institution between February 2017 and February 2022. Differences in pressure, diameter, and distensibility index were obtained by using propofol-based TIVA versus sevoflurane-based GAIA with a 30 mL and a 60 mL balloon. The differences were divided into terciles and compared between diagnoses by using univariate comparisons and logistic regression models.

RESULTS

A total of 49 patients were included (39% type I achalasia, 43% type II or III achalasia, and 18% jackhammer esophagus [JE]). Compared with spastic disorders (types II and III achalasia and JE), type I had lower values of pressure differences at 60 mL in univariate (3.75 vs 15.20, P = .001) and multivariate (adjusted odds ratio, .89; 95% confidence interval, .82-.978) analyses. Compared with type I, types II and III achalasia had higher rates of pressure differences at 60 mL in the univariate (9.85 vs 3.75, P = .04) analysis and nearly reached significance in the multivariate analysis (1.09; 95% confidence interval, 1-1.20). Compared with type I achalasia, JE exhibited higher values in pressure differences at 60 mL (27.7 vs 3.75, P < .001).

CONCLUSIONS

Esophageal pressure, as measured by EndoFLIP, was significantly reduced when patients were sedated with sevoflurane-based GAIA. The use of sevoflurane-based GAIA for diagnostic EndoFLIP may potentially lead to the misclassification of spastic disorders as type I achalasia. Propofol-based TIVA should therefore be considered over sevoflurane-based GAIA for sedation during the diagnostic test.

Enhanced recovery after surgery (ERAS) in advanced therapeutic flexible endoscopy: Introducing the concept of enhanced recovery after therapeutic endoscopy (ERATE)

Enhanced recovery after surgery (ERAS) guidelines are evidence-based recommendations designed to improve patient outcomes and reduce complications after surgery. Although the ERAS guidelines focus primarily on surgical procedures, many of the principles could be applied also to therapeutic endoscopy as well. An extensive literature research on Embase and PubMed was thus made to reviewed articles regarding ERAS protocols applied to therapeutic endoscopy, organized by specific endoscopic field. Out of 214 papers, only 6 were relevant to the topic. Few studies explored in real life and in trial setting the hypothesized significance of ERAS principles applied to endoscopic procedures, mostly retrospective, not even covering the entire field of therapeutic endoscopy. This field of knowledge appears neglected so far by scientific community and endoscopic organizations. We believe that endoscopy units could benefit anyway from developing and implementing structured enhanced recovery pathways for their patients, therefore we subsequently created and suggested a simply and easily applicable, Enhanced Recovery protocol After Therapeutic Endoscopy which include preoperative preparation, anesthesia and sedation, nausea and vomiting (PONV) prophylaxis, and postoperative care.

Feasibility of Enhanced Recovery After Surgery Protocols Implemented Perioperatively in Endoscopic Submucosal Dissection for Early Gastric Cancer: A Single-Center Retrospective Study

Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has advantages over traditional radical gastrectomy. We investigated whether enhanced recovery after surgery (ERAS) protocols are appropriate in the ESD perioperative period. Materials and Methods: We screened 129 consecutive patients, and 12 were excluded. All study patients underwent ESD for EGC. Of the 117 included patients, 57 received traditional perioperative care between January 2017 and December 2018, and 60 patients received perioperative care according to ERAS protocols between January 2019 and September 2020. The primary study endpoint was ESD-related complications. Secondary endpoints included the following postoperative parameters: anal exhaust time, incidence of nausea or vomiting, length of hospitalization, fever rate, abdominal pain on the visual analog scale (VAS), and reported perioperative satisfaction. Results: Complications were comparable between the 2 groups. In the ERAS group, no patients experienced delayed bleeding or perforation. One traditional group patient bled, and one perforated. Postoperative anal exhaust time, nausea or vomiting incidence, hospitalization, fever rate, and VAS pain scores were significantly lower, and perioperative satisfaction rate was significantly higher in the ERAS group. Conclusions: ERAS protocols are both feasible and safe for patients undergoing ESD. ERAS protocols enhance the advantages of ESD for EGC without increasing complications.

Clinical Outcomes and Adverse Events of Gastric Endoscopic Submucosal Dissection of the Mid to Upper Stomach under General Anesthesia and Monitored Anesthetic Care

Background/Aims

Endoscopic submucosal dissection (ESD) of gastric tumors in the mid-to-upper stomach is a technically challenging procedure. This study compared the therapeutic outcomes and adverse events of ESD of tumors in the mid-to-upper stomach performed under general anesthesia (GA) or monitored anesthesia care (MAC).

Methods

Between 2012 and 2018, 674 patients underwent ESD for gastric tumors in the midbody, high body, fundus, or cardia (100 patients received GA; 574 received MAC). The outcomes of the propensity score (PS)-matched (1:1) patients receiving either GA or MAC were analyzed.

Results

The PS matching identified 94 patients who received GA and 94 patients who received MAC. Both groups showed high rates ofen bloc resection (GA, 95.7%; MAC, 97.9%; p=0.68) and complete resection (GA, 81.9%; MAC, 84.0%; p=0.14). There were no significant differences between the rates of adverse events (GA, 16.0%; MAC, 8.5%; p=0.18) in the anesthetic groups. Logistic regression analysis indicated that the method of anesthesia did not affect the rates of complete resection or adverse events.

Conclusions

ESD of tumors in the mid-to-upper stomach at our high-volume center had good outcomes, regardless of the method of anesthesia. Our results demonstrate no differences between the efficacies and safety of ESD performed under MAC and GA.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Efficacy of Endoscopic Submucosal Dissection of Esophageal Neoplasms under General Anesthesia

Background/Aims

Evidence that general anesthesia (GA) reduces the operative time of esophageal endoscopic submucosal dissection (ESD) is currently insufficient. This study aims to evaluate the efficacy and safety of esophageal ESD under GA.

Methods

A total of 227 lesions from 198 consecutive patients with superficial esophageal neoplasms treated by ESD at 3 Japanese institutions between April 2011 and September 2017 were included in this retrospective study. For ESD, GA and deep sedation (DS) were used in 102 (51.5%, GA group) and 96 patients (48.5%, DS group), respectively.

Results

There were no statistically significant differences in age, sex, or comorbidities between the groups. In the GA group, the tumor size was larger (21 [3–77] mm vs. 14 [3–63] mm, p<0.001), luminal circumference was larger (≥2/3; 13.9% vs. 5.4%, p=0.042), procedure time was shorter (28 [5–202] min vs. 40 [8–249] min, p<0.001), and submucosal dissection speed was faster (25.2 [7.8–157.2] mm² /min vs. 16.2 [2.4–41.3] mm² /min, p<0.001). The rates of intraoperative perforation and aspiration pneumonia were lower in the GA group, but the difference did not achieve statistical significance (p=0.242 and p=0.242).

Conclusions

GA shortens the procedure time of esophageal ESD.

Propofol sedation without endotracheal intubation is safe for endoscopic submucosal dissection in the esophagus and stomach

Background

Endoscopic submucosal dissection (ESD) for early esophageal and stomach cancer is usually performed under general anesthesia. However, propofol sedation without endotracheal intubation has been suggested as a viable alternative.

Objective

The objective of this study was to evaluate the safety of propofol sedation without endotracheal intubation during ESD in the upper gastrointestinal tract.

Methods

We performed a retrospective cohort study of patients who underwent ESD for upper gastrointestinal tumors with propofol-remifentanil analgosedation in a tertiary referral center in the Netherlands between October 2013 and February 2018. Primary endpoints were the rates of intraprocedural endoscopy- and anesthesia-related complications. Secondary endpoints were the postprocedural complication rates within 30 days and endotracheal intubation conversion rates.

Results

Of 88 patients, intraprocedural ESD-related complications occurred in three patients (3.4%). Intraprocedural anesthesia-related complications occurred in two patients (2.3%), one of whom required conversion to endotracheal intubation. Postprocedural ESD-related complications occurred in 14 patients (15.9%), and minor postprocedural complications occurred in two patients (2.3%). Eighty-two (93.2%) patients were discharged within one day after ESD. No patient was readmitted for anesthesia-related complications.

Conclusion

Propofol-based sedation without endotracheal intubation is safe for ESD procedures in the esophagus and stomach with low anesthesia-related complication rates and short hospital stay.