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Ikebuchi Y, Matsumoto K, Ueda N, Yamashita T, Kurumi H, Onoyama T, Takeda Y, Yoshida A, Kawaguchi K, Yashima K, Fujiwara K, Imamoto R, Noma H, Ueki M, Isomoto H. Efficacy and Safety of a Novel Mouthpiece for Esophagogastroduodenoscopy: A Multi-Center, Randomized Study. Diagnostics (Basel) 2021; 11:diagnostics11030538. [PMID: 33802944 PMCID: PMC8002750 DOI: 10.3390/diagnostics11030538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
This randomized trial aimed to compare the safety and efficacy of the GAGLESS mouthpiece for esophagogastroduodenoscopy (EGD) with that of the conventional mouthpiece. In all, 90 participants were divided into the GAGLESS mouthpiece and conventional mouthpiece groups. The primary endpoint was the severity of pain using the visual analog scale (VAS), and secondary endpoints were examination time, past history of endoscopy, success of the procedure, systolic (SBP) and diastolic (DBP) blood pressure, oxygen saturation, pulse rate before and after EGD, and adverse events. Endoscopy was completed in all cases, and no complications were observed. VAS, when passing the scope through the pharynx, was 2.5 ± 2.4 and 2.0 ± 1.9 cm (p = 0.24) in the conventional and GAGLESS groups, respectively, and that, throughout the examination, was 2.5 ± 2.4 and 1.7 ± 1.5 cm (p = 0.06), respectively. The difference in blood pressure between the GAGLESS and conventional groups was not significant for SBP (p = 0.08) and significant for DBP (p = 0.03). The post-EGD difference in DBP was significantly lower in the GAGLESS group than in the conventional group. The results indicate that GAGLESS mouthpieces had a lower VAS during endoscopy than the conventional mouthpieces, and the changes in blood pressure were smaller with the GAGLESS mouthpiece.
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Affiliation(s)
- Yuichiro Ikebuchi
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
- Correspondence: (Y.I.); (K.M.)
| | - Kazuya Matsumoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
- Irisawa Medical Clinic, Shimane 690-0025, Japan;
- Correspondence: (Y.I.); (K.M.)
| | - Naoki Ueda
- Irisawa Medical Clinic, Shimane 690-0025, Japan;
- Department of Gastroenterology, Yasugi Municipal Hospital, Shimane 692-0404, Japan; (R.I.); (H.I.)
| | - Taro Yamashita
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Hiroki Kurumi
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Takumi Onoyama
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Yohei Takeda
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Akira Yoshida
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Koichiro Kawaguchi
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Kazuo Yashima
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.Y.); (H.K.); (T.O.); (Y.T.); (A.Y.); (K.K.); (K.Y.)
| | - Kazunori Fujiwara
- Department of Otolaryngology, Head and Neck Surgery, Division of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan;
| | - Ryu Imamoto
- Department of Gastroenterology, Yasugi Municipal Hospital, Shimane 692-0404, Japan; (R.I.); (H.I.)
| | - Hisashi Noma
- The Institute of Statistical Mathematics, Tokyo 190-8562, Japan;
| | - Masaru Ueki
- Advanced Medicine, Innovation and Clinical Research Center, Tottori University Hospital, Tottori 683-8504, Japan;
| | - Hajime Isomoto
- Department of Gastroenterology, Yasugi Municipal Hospital, Shimane 692-0404, Japan; (R.I.); (H.I.)
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Song P, Li J, Zhang Q, Gao S. Ultrathin endoscopy versus computed tomography in the detection of anastomotic leak in the early period after esophagectomy. Surg Oncol 2019; 32:30-34. [PMID: 31715559 DOI: 10.1016/j.suronc.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 06/03/2019] [Accepted: 10/28/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Anastomotic leak after esophagectomy is a major postoperative complication that leads to significant mortality. The aim of this study was to evaluate the safety of early postoperative ultrathin endoscopy in detecting anastomotic leaks and compare diagnostic performance of ultrathin endoscopy and computed tomography (CT) scan in identifying anastomotic leak after esophagectomy. MATERIALS AND METHODS A prospective trial of 71 patients undergoing esophagectomy was conducted between January 2016 to December 2017. A contrast CT was performed prior to ultrathin endoscopy on postoperative day 5-7. RESULTS All 71 patients underwent ultrathin endoscopy and CT scan safely without complications. Among the 71 patients, transoral ultrathin endoscopy was performed on 51 patients and 20 patients with hypertension and coronary artery disease received transnasal ultrathin endoscopy. Overall, 14 leaks (20%) were identified. Endoscopy not only correctly identified the 2 patients of false-positive evaluations by CT, but also determined 4 leaks that were missed on CT. In addition, ultrathin endoscopy accurately identified 3 potential leaks based on pathological findings of anastomosis: ischemia and much fibrin coverings. One patient with normal postoperative CT findings showed healthy anastomosis but an ulcer on gastric conduit on endoscopy. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of CT were 71.4% and 96.5%. CONCLUSIONS Ultrathin endoscopy after esophagectomy is safe and provides more accurate and reliable identification of anastomotic leak than CT scan. Ultrathin transnasal endoscopy may be a more appropriate diagnostic test to detect anastomosis for patients with hypertension and coronary artery disease.
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Affiliation(s)
- Peng Song
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jiagen Li
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Qingrui Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Abstract
PURPOSE OF REVIEW There has been an exponential increase in the incidence of esophageal adenocarcinoma (EAC) over the last half century. Barrett's esophagus (BE) is the only known precursor lesion of EAC. Screening for BE in high-risk populations has been advocated with the aim of identifying BE, followed by endoscopic surveillance to detect dysplasia and early stage cancer, with the intent that treatment can improve outcomes. We aimed to review BE screening methodologies currently recommended and in development. RECENT FINDINGS Unsedated transnasal endoscopy allows for visualization of the distal esophagus, with potential for biopsy acquisition, and can be done in the office setting. Non-endoscopic screening methods being developed couple the use of swallowable esophageal cell sampling devices with BE specific biomarkers, as well as trefoil factor 3, methylated DNA markers, and microRNAs. This approach has promising accuracy. Circulating and exhaled volatile organic compounds and the foregut microbiome are also being explored as means of detecting EAC and BE in a non-invasive manner. Non-invasive diagnostic techniques have shown promise in the detection of BE and may be effective methods of screening high-risk patients.
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Affiliation(s)
- Don C Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Vicari JJ. Sedation in the Ambulatory Endoscopy Center: Optimizing Safety, Expectations and Throughput. Gastrointest Endosc Clin N Am 2016; 26:539-52. [PMID: 27372776 DOI: 10.1016/j.giec.2016.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the United States, sedation and analgesia are the standard of practice when endoscopic procedures are performed in the ambulatory endoscopy center. Over the last 30 years, there has been a dramatic shift of endoscopic procedures from the hospital outpatient department to ambulatory endoscopy centers. This article will discuss sedation and analgesia in the ambulatory endoscopy center as it relates to optimizing safety, patient expectations, and efficiency.
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Affiliation(s)
- Joseph J Vicari
- Rockford Gastroenterology Associates, Ltd, 401 Roxbury Road, Rockford, IL 61107, USA; Department of Medicine, University of Illinois College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107, USA.
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Kim CY, O'Rourke RW, Chang EY, Jobe BA. Unsedated Small-Caliber Upper Endoscopy: An Emerging Diagnostic and Therapeutic Technology. Surg Innov 2016; 13:31-9. [PMID: 16708153 DOI: 10.1177/155335060601300106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although conventional esophagogastroduodenoscopy has become widespread in its applications and availability, it is constrained by the requirement for patient sedation. This requirement contributes to morbidity, time lost from work, and additional resource utilization in personnel and facilities. Small-caliber endoscopy is an emerging technology that enables transnasal evaluation of the upper gastrointestinal tract in a unsedated patient. This procedure can be performed in a wider range of settings, including the clinic setting where a dedicated conscious sedation suite is not available and can be incorporated into the office visit. The applications of small-caliber endoscopy include general diagnostic upper endoscopy, screening and surveillance of Barrett esophagus, and intraoperative diagnostics or postoperative evaluation of the upper gastrointestinal tract. Therapeutic applications include the placement of nasoduodenal feeding tubes, esophageal pH catheters, and impedance catheters. When used in the sedated patient, small-caliber endoscopy can also facilitate esophageal stricture dilation and transnasal placement of a percutaneous endoscopic gastrostomy tube. This review discusses the techniques, equipment, and applications of small-caliber endoscopy of the upper gastrointestinal tract.
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Affiliation(s)
- Charles Y Kim
- Department of Surgery, Oregon Health and Science University, Portland Veteran's Administration Medical Center, Portland, Oregon 97207, USA
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Ulusoy H, Coskun I, Arslan M. Effects of midazolam or tramadol premedication on early cognitive function in endoscopic retrograde cholangiopancreatography (ERCP): A randomized, controlled, double-blind study. J Int Med Res 2016; 44:542-56. [PMID: 26944385 PMCID: PMC5536697 DOI: 10.1177/0300060515600189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/22/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the sedative efficacy and effects on early period cognitive function of premedication in endoscopic retrograde cholangiopancreatography (ERCP). METHODS Forty patients (18-70 years; American Society of Anesthesiology risk category I-III) undergoing elective ERCP were randomized to receive oral premedication with 0.15 mg/kg midazolam or 1 mg/kg tramadol. Cognitive function was determined by mini-mental test (MMT). Target scores for effective sedation were determined as a Bispectral index score of 70-90 and modified Ramsay Sedation Scale score (mRSS) of 2-4. RESULTS Global MMT score was not significantly different between treatment groups at 60 min post-ERCP. A significant deterioration in the MMT subcategory of recall was determined in with midazolam versus tramadol. Level of sedation (mRSS) was higher in with midazolam compared with tramadol reaching statistical significance at 30 min after drug administration. CONCLUSIONS Although more effective sedation was obtained with midazolam in patients undergoing ERCP, there was a dysfunction in memory recall. It was concluded, however, that early cognitive functions were generally preserved with both drugs.
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Affiliation(s)
- Hulya Ulusoy
- Department of Anesthesiology and Critical Care, Karadeniz Technical University, Faculty of Medicine, TRABZON, Turkey
| | | | - Mehmet Arslan
- Department of Gastroenterology, Karadeniz Technical University, Faculty of Medicine, TRABZON, Turkey
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Sami SS, Ragunath K, Iyer PG. Screening for Barrett's esophagus and esophageal adenocarcinoma: rationale, recent progress, challenges, and future directions. Clin Gastroenterol Hepatol 2015; 13:623-34. [PMID: 24887058 PMCID: PMC4254386 DOI: 10.1016/j.cgh.2014.03.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/26/2014] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
As the incidence and mortality of esophageal adenocarcinoma continue to increase, strategies to counter this need to be explored. Screening for Barrett's esophagus, which is the known precursor of a large majority of adenocarcinomas, has been debated without a firm consensus. Given evidence for and against perceived benefits of screening, the multitude of challenges in the implementation of such a strategy and in the downstream management of subjects with Barrett's esophagus who could be diagnosed by screening, support for screening has been modest. Recent advances in the form of development and initial accuracy of noninvasive tools for screening, risk assessment tools, and biomarker panels to risk stratify subjects with BE, have spurred renewed interest in the early detection of Barrett's esophagus and related neoplasia, particularly with the advent of effective endoscopic therapy. In this review, we explore in depth the potential rationale for screening for Barrett's esophagus, recent advances that have the potential of making screening feasible, and also highlight some of the challenges that will have to be overcome to develop an effective approach to improve the outcomes of subjects with esophageal adenocarcinoma.
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Affiliation(s)
- Sarmed S. Sami
- University of Nottingham, Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham, United Kingdom
| | - Krish Ragunath
- University of Nottingham, Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham, United Kingdom
| | - Prasad G. Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester
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O'Brien C, Urquhart CS, Allam S, Anderson KJ, Leitch JA, Macpherson A, Kenny GNC. Reaction time-monitored patient-maintained propofol sedation: a pilot study in oral surgery patients. Anaesthesia 2013; 68:760-4. [PMID: 24044388 DOI: 10.1111/anae.12291] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2013] [Indexed: 11/28/2022]
Abstract
Previous volunteer studies of an effect-site controlled patient-maintained sedation system using propofol have demonstrated a risk of oversedation. We have incorporated a reaction time monitor into the handset to add an individualised patient-feedback mechanism. This pilot study assessed if the reaction time-feedback modification would prove safe and effective in 20 healthy patients receiving sedation while undergoing oral surgery. All patients successfully sedated themselves without reaching any unsafe endpoints. All 20 maintained verbal contact throughout. The mean (SD) lowest peripheral blood oxygen saturation was 98.0 (2.1)% breathing room air. No patient required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.6 (0.5) μg.ml(-1). The present system was found to be safe and effective, allowing oral surgery treatment under conscious sedation, but preventing oversedation.
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Affiliation(s)
- C O'Brien
- University of Glasgow Dental School, Glasgow, UK
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Hsieh YH, Lin HJ, Hsieh JJ, Tseng KC, Tseng CW, Hung TH, Leung FW. Meperidine as the single sedative agent during esophagogastroduodenoscopy, a double-blind, randomized, controlled study. J Gastroenterol Hepatol 2013; 28:1167-73. [PMID: 23431993 DOI: 10.1111/jgh.12183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM In Taiwan, unsedated esophagogastroduodenoscopy (EGD) is widely used, but it is uncomfortable for some patients. While meperidine has been adopted in colonoscopy, its use in EGD has not received extensive attention. This was a prospective study to investigate the use of meperidine as a single sedative agent during EGD. METHODS One hundred and forty patients were randomized to receive either 25-mg meperidine (n = 70) or placebo (n = 70) by intramuscular injection before EGD. The primary outcome was patient discomfort scores. The secondary outcomes included patient, endoscopist, and EGD-related variables. RESULTS Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 2.0 and interquartile range [IQR] of 0-4.0 vs median score of 4.8 and IQR of 1.7-7.0, respectively; P < 0.001) and during the procedure (median score of 1.0 [IQR 0-3.1] vs 3.5 [IQR 0-5.6], P = 0.001) than patients in the placebo group. The endoscopist found patients in the meperidine group had better tolerance during esophageal intubation (median score of 1.0 [IQR 0-2.0] vs 2.0 [IQR 1.0-3.0], P = 0.021) and during the procedure (median score of 0 [IQR 0-1.0] vs 1.0 [IQR 0-3.0], P < 0.001). After the procedure more patients in the meperidine group (71.4% vs 35.7%, P < 0.001) experienced self-limited dizziness that prolonged recovery by ∼3.7 min. CONCLUSIONS After receiving meperidine injection, patients had better tolerance and less discomfort during diagnostic EGD (NCT01547520).
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Affiliation(s)
- Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Chia-Yi, Taiwan.
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Miyake K, Kusunoki M, Ueki N, Yamada A, Nagoya H, Kodaka Y, Shindo T, Kawagoe T, Gudis K, Futagami S, Tsukui T, Sakamoto C. Classification of patients who experience a higher distress level to transoral esophagogastroduodenoscopy than to transnasal esophagogastroduodenoscopy. Dig Endosc 2013; 25:397-405. [PMID: 23368664 DOI: 10.1111/den.12006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 10/15/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND In Japanese routine clinical practice, endoscopy is generally carried out without sedation. The present study aimed to identify the factors essential for appropriate selection of transnasal esophagogastroduodenoscopy (TN-EGD) as an alternative to unsedated transoral esophagogastroduodenoscopy (TO-EGD). PATIENTS AND METHODS Subjects in this prospective cohort study comprised consecutive outpatients who underwent EGD at a single center. Factors predicting TO-EGD-induced distress were evaluated on a visual analog scale (VAS) and analyzed. Patients were classified into a two-layered system on the basis of these predictive factors, and the severity of distress between the TN-EGD and TO-EGD groups was compared using VAS and the change in the rate-pressure product as subjective and objective indices, respectively. RESULTS In total, 728 outpatients (390 male, 338 female; mean age, 63.1 ± 0.5 years; TO-EGD group, 630; TN-EGD group, 98)met the inclusion criteria. Multivariate logistic regression analysis confirmed that age <65 years (P < 0.01; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.14-2.52), gender (female; P < 0.01; OR,1.97; 95% CI, 1.34-2.91), marital status (single; P < 0.01; OR, 1.96; 95% CI, 1.18-3.27), and anxiety towards TO-EGD (P < 0.001; OR, 3.62; 95% CI, 2.44-5.37) were independently associated with intolerance. Both indices were significantly higher in the TO-EGD subgroup than in the TN-EGD subgroup in the high predictive class, but not in the low predictive class. CONCLUSION Predictive factors for detecting intolerance to unsedated TO-EGD may be useful to appropriately select patients who transpose unsedated TO-EGD to TN-EGD.
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Affiliation(s)
- Kazumasa Miyake
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan.
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Terui T, Inomata M. Administration of additional analgesics can decrease the incidence of paradoxical reactions in patients under benzodiazepine-induced sedation during endoscopic transpapillary procedures: prospective randomized controlled trial. Dig Endosc 2013; 25:53-9. [PMID: 23286257 DOI: 10.1111/j.1443-1661.2012.01325.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 03/26/2012] [Indexed: 02/08/2023]
Abstract
AIM The aim of the present study was to evaluate the efficacy and safety of giving pentazocine as an analgesic with benzodiazepine during endoscopic retrograde cholangiopancreatography (ERCP). METHODS The paradoxical reactions (PR) incidence was evaluated as an indicator of usefulness. Transcutaneous arterial carbon dioxide tension (PtcCO(2) ) was evaluated as an indicator of safety. A total of 160 patients were enrolled. Subjects were randomly divided into two groups; group 1 sedated with midazolam only and group 2 sedated both with midazolam and pentazocine (7.5 mg). RESULTS The initial dosage introduced sedation before procedure was significantly higher in group 1. The occurrence rate of PR's in group 1 was significantly higher compared to that in group 2 (P = 0.0108). Although maximum PtcCO(2) observed during sedation did not differ between the two groups (48.7 ± 7.2, 50.3 ± 7.6 mmHg, respectively),maximum PtcCO(2) during the first 15 min after the start of sedation was significantly higher in group 2 than in group 1 (P = 0.0294). In multivariate analysis, procedure duration (odds ratio [OR] = 1.048) and midazolam dose (OR = 1.221) were predictive factors for PR. CONCLUSION The administration of pentazocine is significantly reduced the incidence of PR's in patients under midazolam induced sedation during ERCP.
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Affiliation(s)
- Torahiko Terui
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
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Allam S, Anderson KJ, O'Brien C, Macpherson JA, Gambhir S, Leitch JA, Kenny GNC. Patient-maintained propofol sedation using reaction time monitoring: a volunteer safety study. Anaesthesia 2012; 68:154-8. [PMID: 23153106 DOI: 10.1111/anae.12036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Previous volunteer studies of an effect-site controlled, patient-maintained sedation system using propofol have demonstrated a risk of over-sedation. We have incorporated a reaction-time monitor into the handset of the patient-maintained sedation system to add an individualised patient-feedback mechanism. This study assessed if such reaction-time feedback modification would reduce the risk of over-sedation in 20 healthy volunteers deliberately attempting to over-administer themselves propofol. All the volunteers successfully sedated themselves without reaching any unsafe endpoints. All volunteers maintained verbal contact throughout, in accordance with the definition of conscious sedation. The mean (SD) lowest S(p) O(2) was 97 (1.7) % when breathing room air and no volunteer required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.7 (0.4) μg.ml(-1) . The present system was found to be safer than its predecessors, allowing conscious sedation, but preventing over-sedation.
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Affiliation(s)
- S Allam
- Department of Anaesthesia, Forth Valley Royal Hospital, Larbert, UK.
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Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients. Eur J Gastroenterol Hepatol 2012; 24:1214-8. [PMID: 22786572 DOI: 10.1097/meg.0b013e328356ae49] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM The objective of this study was to determine the frequency of clinically overt hepatic encephalopathy (HE) in cirrhotic patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy (UGE) who received midazolam for sedation. METHODS This was an interventional study carried out at Liaquat National Hospital, Karachi. Consecutive patients presenting to the service of a single consultant gastroenterologist for diagnostic or therapeutic UGE between January 2009 and January 2011, who fulfilled the inclusion and exclusion criteria, were prospectively recruited for the study. The administration of intravenous midazolam was carried out in an incremental manner, whereas pulse and oxygen saturation was monitored during every procedure. During the recovery period, the degree of alertness was measured at 2, 4, and 6 h by the resident using the observer's assessment of alertness and sedation score and time to full recovery was determined. RESULTS A total of 191 consecutive patients who underwent diagnostic or therapeutic UGE fulfilling the inclusion and exclusion criteria were recruited. The mean age was 51.30 ± 10.7 years, with an age range of 12-75 years. The majority of the patients were men (n=108, 56.5%), with 83 women (43.5%). A total of eight patients (4.2%) remained drowsy and developed clinically overt HE after the procedure on assessment at 2 and 4 h. However, all of these patients regained full consciousness at 6 h spontaneously. Among those eight patients who developed clinically overt HE, seven (87.5%) were Child-Pugh class C and one patient (12.5%) was Child-Pugh class B. Overt HE was significantly related to Child-Pugh class (P=0.005) and the dose of midazolam (P=0.02). CONCLUSION We concluded that intravenous midazolam can be used safely in cirrhotic patients of Child-Pugh class A and B undergoing UGE for conscious sedation, but caution should be exercised for patients with advanced liver disease.
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Upper and lower gastrointestinal endoscopy mortality: the medical examiner’s perspective. Forensic Sci Med Pathol 2011; 8:4-12. [DOI: 10.1007/s12024-011-9257-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2011] [Indexed: 12/23/2022]
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Maslekar S, Balaji P, Gardiner A, Culbert B, Monson JRT, Duthie GS. Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol. Colorectal Dis 2011; 13:48-57. [PMID: 19575742 DOI: 10.1111/j.1463-1318.2009.01988.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes). METHOD One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure. RESULTS The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability. CONCLUSION Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.
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Affiliation(s)
- S Maslekar
- University of Hull, Castle Hill Hospital, Hull, UK
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Aymaz S, Krakamp B, Kirschberg O, Lefering R. Comparability of localization data in transnasal and transoral esophagogastroduodenoscopy. BMC Gastroenterol 2010; 10:116. [PMID: 20939930 PMCID: PMC2964604 DOI: 10.1186/1471-230x-10-116] [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: 03/22/2010] [Accepted: 10/13/2010] [Indexed: 11/29/2022] Open
Abstract
Background Esophagogastroduodenoscopy is an often-used and safe diagnostic method in gastroenterology. Transnasal esophagogastroduodenoscopy is now an established addition to the endoscopic instrumentarium. Although the two examination methods can be used alongside each other, there is a lack of studies on the comparability of the localization data obtained with the transoral and transnasal methods. Methods In 135 adult patients presenting for routine outpatient esophagogastroduodenoscopy, transoral esophagogastroduodenoscopy (TOG) was carried out after transnasal esophagogastroduodenoscopy (TNG), and the distance from the naris or incisors, respectively, to the esophagogastric junction was measured. Results The data for 135 patients were analyzed. With the transoral access route, the distance from the upper incisors to the cardia was a mean of 40.5 cm (SD ± 3.4 cm). In the transnasal examinations, the mean distance between the naris and the cardia was 45.6 cm (SD ± 3.5 cm). The correlation analysis showed a very close correlation between the peroral and transnasal data, with a correlation coefficient of r = 0.925. On the basis of the regression line calculated using these data, the formula TNG (cm) = 1.1 × TOG (cm) was developed. Using this formula, localization details obtained with one method can be converted into those for the other method. Conclusions There is a strong correlation between the localization details obtained with the transnasal and transoral examination methods. The formula for converting localization details from one method to the other, presented here for the first time, is practicable for everyday use and allows rapid conversion.
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Affiliation(s)
- Serhat Aymaz
- Department of Internal Medicine, Holweide Hospital, City of Cologne Hospitals, Ltd,, Cologne, Germany.
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Toyoizumi H, Kaise M, Arakawa H, Yonezawa J, Yoshida Y, Kato M, Yoshimura N, Goda KI, Tajiri H. Ultrathin endoscopy versus high-resolution endoscopy for diagnosing superficial gastric neoplasia. Gastrointest Endosc 2009; 70:240-5. [PMID: 19386304 DOI: 10.1016/j.gie.2008.10.064] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 10/31/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ultrathin endoscopy (UTE) is an acceptable and cost-effective alternative to EGD with the patient under sedation, although the diagnostic accuracy of UTE is not well established. OBJECTIVE To compare the diagnostic accuracy of UTE and high-resolution endoscopy (HRE) for superficial gastric neoplasia. DESIGN Prospective comparative study. SETTING Academic center. PATIENTS AND INTERVENTIONS Patients with or without superficial gastric neoplasia underwent peroral UTE and HRE, back-to-back in a random order while under standard sedation. The procedures were performed by 2 endoscopists who were blinded to the clinical information. MAIN OUTCOME MEASUREMENTS The rate of missed lesions and misdiagnosis, sensitivity, and specificity for the diagnosis of gastric neoplasia when using pathology as the reference standard. RESULTS In total, 126 lesions (41 superficial gastric neoplasias, 85 nonneoplastic lesions) were recorded in 57 enrolled patients. For the diagnosis of gastric neoplasia, the sensitivity of UTE (58.5%) was significantly (P = .021) lower than that of HRE (78%), and the specificity of UTE (91.8%) was significantly (P = .014) lower than that of HRE (100%). The rate of missed lesions and misdiagnosis of gastric neoplasias when using UTE (41.5%) was significantly (P > .001) higher than that of HRE (22.0%). The corresponding rate of neoplasias at the proximal portion (fornix and corpus) when using UTE (29%) was significantly (P = .002) higher than that of HRE (7.2%), although the rates of neoplasias at the distal portion (angulus and antrum) were comparable for UTE and HRE. LIMITATION Small sample numbers in an enriched population. CONCLUSIONS The diagnostic accuracy of UTE is significantly lower than that of HRE for superficial gastric neoplasia, and this difference is particularly striking for neoplasias in the proximal stomach. For UTE to be used as an alternative modality, improvements in optical quality and the incorporation of additional procedures, including close-range observations and chromoendoscopy, are required to enhance visualization.
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Affiliation(s)
- Hirobumi Toyoizumi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
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Robertson DJ, Jacobs DP, Mackenzie TA, Oringer JA, Rothstein RI. Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy. Aliment Pharmacol Ther 2009; 29:817-23. [PMID: 19154568 DOI: 10.1111/j.1365-2036.2009.03943.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little evidence to guide choice between meperidine (pethidine) and fentanyl for sedation for gastrointestinal endoscopy. AIM To compare meperidine with fentanyl in terms of procedure time and analgesia. METHODS Single centre randomized controlled trial. Patients received narcotic doses and midazolam at the discretion of the attending endoscopist who was unaware of narcotic assignment. Endoscopy and recovery times were then recorded. The main outcome was total procedure time, defined as endoscopy time plus recovery time. Patient discomfort was assessed prior to discharge via visual analogue scale (VAS). RESULTS In total, 55 patients were randomized to meperidine [44 colonoscopy and 11 esophagogastroduodenoscopy (EGD)] and 56 to fentanyl (45 colonoscopy and 11 EGD). Total procedure time was shorter for those receiving fentanyl (mean = 87.7 min) than for those receiving meperidine (mean = 102.9 min) (P = 0.05). The difference between the groups was explained by a shorter mean recovery time in the fentanyl group (63.0 min) than in the meperidine group (76.2 min) (P = 0.07). Based on post procedure pain scores, examinations with meperidine (mean = 1.99) were less painful when compared with those receiving fentanyl (mean = 2.86, P = 0.03). CONCLUSIONS Fentanyl shortened total procedure time by reducing recovery time. A simple change in narcotic choice could increase endoscopy unit efficiency.
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Affiliation(s)
- D J Robertson
- VA Medical Center, White River Junction, VT 05009, USA.
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Maslekar S, Gardiner A, Hughes M, Culbert B, Duthie GS. Randomized clinical trial of Entonox versus midazolam-fentanyl sedation for colonoscopy. Br J Surg 2009; 96:361-8. [PMID: 19283736 DOI: 10.1002/bjs.6467] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam-fentanyl for colonoscopy. METHODS Some 131 patients undergoing elective colonoscopy were included. Patients completed a Hospital Anxiety and Depression questionnaire, letter cancellation tests and pain scores on a 100-mm visual analogue scale before, immediately after the procedure and at discharge. They also completed a satisfaction survey at discharge and 24 h after the procedure. RESULTS Sixty-five patients were randomized to receive Entonox and 66 to midazolam-fentanyl. Completion rates were similar (94 versus 92 per cent respectively; P = 0.513). Patients receiving Entonox had a shorter time to discharge. They reported significantly less pain (mean score 16.7 versus 40.1; P < 0.001), and showed better recovery of psychomotor function immediately after the procedure and at discharge. Patient satisfaction was higher among patients who received Entonox (median score 96 versus 89; P = 0.001). CONCLUSION Entonox provides better pain relief and faster recovery than midazolam-fentanyl and so is more effective for colonoscopy.
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Affiliation(s)
- S Maslekar
- Academic Surgical Unit, University of Hull and Castle Hill Hospital, Cottingham, UK
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Sugimoto M, Furuta T, Nakamura A, Shirai N, Ikuma M, Misaka S, Uchida S, Watanabe H, Ohashi K, Ishizaki T, Hishida A. Maintenance time of sedative effects after an intravenous infusion of diazepam: A guide for endoscopy using diazepam. World J Gastroenterol 2008; 14:5197-203. [PMID: 18777597 PMCID: PMC2744010 DOI: 10.3748/wjg.14.5197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine whether the sedative effects assessed by psychomotor tests would depend on the cytochrome P450 (CYP) 2C19 genotypes after an infusion regimen of diazepam commonly used for gastrointestinal endoscopy in Japan.
METHODS: Fifteen healthy Japanese volunteers consisting of three different CYP2C19 genotype groups underwent a critical flicker fusion test, an eye movement analysis and a postural sway test as a test for physical sedative effects, and a visual analog scale (VAS) symptom assessment method as a test for mental sedative effects during the 336 h period after the intravenous infusion of diazepam (5 mg).
RESULTS: The physical sedative effects assessed by the critical flicker test continued for 1 h (t values of 5 min, 30 min and 60 min later: 4.35, 5.00 and 3.19, respectively) and those by the moving radial area of a postural sway test continued for 3 h (t values of 5 h, 30 h, 60 min and 3 h later: -4.05, -3.42, -2.17 and -2.58, respectively), which changed significantly compared with the baseline level before infusion (P < 0.05). On the other hand, the mental sedative effects by the VAS method improved within 1 h. The CYP2C19 genotype-dependent differences in the postinfusion sedative effects were not observed in any of the four psychomotor function tests.
CONCLUSION: With the psychomotor tests, the objective sedative effects of diazepam continued for 1 h to 3 h irrespective of CYP2C19 genotype status and the subjective sedative symptoms improved within 1 h. Up to 3 h of clinical care appears to be required after the infusion of diazepam, although patients feel subjectively improved.
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Abstract
BACKGROUND The benefit of using one or two drugs for conscious sedation in upper endoscopy remains unproven. This study evaluates the adequacy of conscious sedation during upper endoscopy using midazolam alone compared with midazolam plus fentanyl. METHODS Patients older than 18 years of age who underwent elective, outpatient upper endoscopy were included. They were randomized to receive either a combination of midazolam/fentanyl or midazolam alone. The adequacy of sedation obtained was assessed using a questionnaire answered by the physician at the end of the procedure, and by the patient 24 to 72 hours after endoscopy. RESULTS From the endoscopist's perspective, following an intention-to-treat analysis, patients had better tolerance in the combination group (78.3% excellent/good tolerance M/F group versus 55.8% M group) (P = 0.043) (Table 2). Per patient's assessment excellent/good tolerance was found in 93% of M group and 94% in F/M group (P = 1.0). No difference in duration of the procedure was found between the two groups. No complications during endoscopies were reported. CONCLUSIONS In diagnostic upper endoscopy, an adequate level of sedation can be obtained safely either by midazolam or midazolam plus fentanyl. From an endoscopist's perspective, the combination is significantly better.
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Unsedated transnasal endoscopy: a Canadian experience in daily practice. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:243-6. [PMID: 18354752 DOI: 10.1155/2008/514297] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Esophagogastroduodenoscopy (EGD) is the most frequently performed diagnostic procedure for upper gastrointestinal disorders. The procedure is routinely performed under conscious sedation in North America. A significant proportion of morbidity and mortality associated with EGD is related to hypoxia due to conscious sedation. The use of sedation is also associated with an increase in cost, loss of work on the day of endoscopy and the need for the patient to be accompanied home after the procedure. Transnasal endoscopy has advantages such as no sedation and less patient monitoring, nursing time and expenses than conventional per oral EGD. OBJECTIVES To assess the feasibility and acceptability of unsedated transnasal EGD in daily practice. METHODS Patients due to undergo EGD were given a choice of either unsedated transnasal EGD or per oral EGD with sedation. Patients who chose unsedated transnasal EGD had the procedure performed in the office by a senior gastroenterologist with experience in transnasal EGD. All procedures were performed using a small-calibre esophagogastroduodenoscope. All patients were surveyed using a patient satisfaction questionnaire, and were asked to give specific scores in terms of choking sensation, sore throat, nasal discomfort and abdominal discomfort. All variables were assessed by scores between 0 and 10, with 10 indicating the most severe degree of each variable. Any complications were also recorded. RESULTS Between March 2002 and August 2003, 231 patients underwent transnasal EGD. The median age of the patients was 57 years (range 15 to 87 years). Complete examinations were possible in 98% of patients. Patients reported a high degree of acceptability (mean score 6.6, range 1 to 10) and low degrees of choking sensation (mean 1.8, range 0 to 10), nasal discomfort (mean 1.7, range 0 to 10), sore throat (mean 0.8, range 0 to 9) and abdominal discomfort (mean 1.1, range 0 to 10). The only complications reported by the patients were epistaxis (n=2, 0.9%) and sinusitis (n=1, 0.4%). Some patients also reported transient light-headedness (n=12, 5%) and mucous discharge (n=2, 0.9%). When asked, 185 patients (88%) stated that they were willing to undergo the same procedure in the future if medically indicated. Of the 84 patients who had conventional EGD under conscious sedation in the past, 52 patients (62%) preferred transnasal EGD without sedation. CONCLUSIONS Transnasal EGD is generally well tolerated, feasible and safe. It can be performed with topical anesthesia in an outpatient setting. The low complication rate, high patient satisfaction and potential cost savings make transnasal endoscopy an attractive alternative to conventional EGD to screen patients for upper gastrointestinal tract diseases.
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Jobe BA, Hunter JG, Chang EY, Kim CY, Eisen GM, Robinson JD, Diggs BS, O'Rourke RW, Rader AE, Schipper P, Sauer DA, Peters JH, Lieberman DA, Morris CD. Office-based unsedated small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett's esophagus: a randomized and blinded comparison. Am J Gastroenterol 2006; 101:2693-703. [PMID: 17227516 DOI: 10.1111/j.1572-0241.2006.00890.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES A major limitation to screening and surveillance of Barrett's esophagus is the complexity, expense, and risk associated with sedation for upper endoscopy. This study examines the feasibility, accuracy, and patient acceptability of office-based unsedated endoscopy as an alternative. METHODS Of 274 eligible adults scheduled for endoscopic screening for gastroesophageal reflux symptoms or surveillance of Barrett's esophagus at a tertiary care center, 121 underwent unsedated small-caliber endoscopy and conventional endoscopy in a randomized crossover study. The two procedures were compared with regard to histological detection of Barrett's esophagus and dysplasia and biopsy size. Patients answered questionnaires assessing the tolerability of the procedures. RESULTS The prevalence of Barrett's esophagus was 26% using conventional endoscopy and 30% using unsedated endoscopy (P= 0.503). The level of agreement between the two approaches was "moderate" (kappa= 0.591). Each modality detected four cases of low-grade dysplasia with concordance on one case. The tissue samples collected with unsedated endoscopy were smaller than with conventional endoscopy (P < 0.001). The majority of subjects rated their experience with both procedures as being well tolerated with minimal or no difficulty. When asked which procedure they would prefer in the future, 71% (81/114) chose unsedated small-caliber endoscopy. CONCLUSIONS Office-based unsedated small-caliber endoscopy is technically feasible, well tolerated, and accurate in screening for Barrett's esophagus, despite yielding a smaller biopsy specimen. This approach bears the potential to eliminate the infrastructure and cost required for intravenous sedation in this application.
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Affiliation(s)
- Blair A Jobe
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Chapman RM, Anderson K, Green J, Leitch JA, Gambhir S, Kenny GNC. Evaluation of a new effect-site controlled, patient-maintained sedation system in dental patients. Anaesthesia 2006; 61:345-9. [PMID: 16548953 DOI: 10.1111/j.1365-2044.2006.04544.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We have designed a new effect-site controlled, patient-maintained sedation system for delivering propofol. In the previous systems we developed, the patients retained the use of the handset throughout the procedure and were able to increase the level of sedation. However, it was found that this could potentially lead to oversedation. In the present system, the patients were able to increase their level of sedation until a level was reached that was judged by the patients as being adequate to allow them to tolerate the injection of dental local anaesthetic. The handset was then taken from the patients and the effect site concentration of propofol was maintained at that level for the remainder of the procedure. To assess its safety and efficacy, the system was used to sedate 40 patients presenting for dental procedures under sedation. The system was used successfully and treatment was completed in 39 patients. The system was found to be safe. Both surgeon and patient approval scores were high. Although this study demonstrates the efficacy of effect-site controlled, patient-maintained propofol sedation in this group of patients, further work is required to confirm its safety.
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Affiliation(s)
- R M Chapman
- Department of Anaesthesia, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK.
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Navigante AH, Cerchietti LCA, Castro MA, Lutteral MA, Cabalar ME. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 2006; 31:38-47. [PMID: 16442481 DOI: 10.1016/j.jpainsymman.2005.06.009] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2005] [Indexed: 01/17/2023]
Abstract
The mainstay of dyspnea palliation remains altering its central perception. Morphine is the main drug and anxiolytics have a less established role. This trial assessed the role of midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in terminally ill cancer patients. One hundred and one patients with severe dyspnea were randomized to receive around-the-clock morphine (2.5 mg every 4 hours for opioid-naïve patients or a 25% increment over the daily dose for those receiving baseline opioids) with midazolam rescue doses (5 mg) in case of breakthrough dyspnea (BD) (Group Mo); around-the-clock midazolam (5 mg every 4 hours) with morphine rescues (2.5 mg) in case of BD (Group Mi); or around-the-clock morphine (2.5 mg every 4 hours for opioid-naïve patients or a 25% increment over the daily dose for those receiving baseline opioids) plus midazolam (5 mg every 4 hours) with morphine rescue doses (2.5 mg) in case of BD (Group MM). All drugs were given subcutaneously in a single-blinded way. Thirty-five patients were entered in Group Mo, 33 entered in Mi, and 33 entered in MM. At 24 hours, patients who experienced dyspnea relief were 69%, 46%, and 92% in the Mo, Mi, and MM groups, respectively (P = 0.0004 and P = 0.03 for MM vs. Mi and MM vs. Mo, respectively). At 48 hours, those with no dyspnea relief (no controlled dyspnea) were 12.5%, 26%, and 4% for the Mo, Mi, and MM groups, respectively (P = 0.04 for MM vs. Mi). During the first day, patients with BD for the groups Mo, Mi, and MM were 34.3%, 36.4%, and 21.2%, respectively (P = NS or not significant), whereas during the second day, these percentages were 38%, 38.5%, and 24%, respectively (P = NS). The data demonstrate that the beneficial effects of morphine in controlling baseline levels of dyspnea could be improved with the addition of midazolam to the treatment.
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Affiliation(s)
- Alfredo H Navigante
- Internal Medicine Department and Translational Research Unit, Angel H. Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
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Abstract
The use of sedation for routine endoscopic procedures, including colonoscopy, varies widely across cultures. This variation in sedation practice is greater than any other culturally based variation in the technical performance of endoscopy. This article sequentially reviews the technical performance of colonoscopy in patients who undergo unsedated colonoscopy, sedation with narcotics and benzodiazepines, and deep sedation with propofol. For each of these approaches to colonoscopy, the advantages and disadvantages also are listed and discussed.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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Faulx AL, Vela S, Das A, Cooper G, Sivak MV, Isenberg G, Chak A. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc 2005; 62:9-15. [PMID: 15990813 DOI: 10.1016/s0016-5107(05)00518-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists' attitudes toward unsedated screening with an electronic survey. METHODS A short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically. RESULTS Two e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barrett's esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures. CONCLUSIONS Electronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists' attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.
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Affiliation(s)
- Ashley L Faulx
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland, Ohio, USA
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Leitch JA, Anderson K, Gambhir S, Millar K, Robb ND, McHugh S, Kenny GNC. A partially blinded randomised controlled trial of patient-maintained propofol sedation and operator controlled midazolam sedation in third molar extractions. Anaesthesia 2004; 59:853-60. [PMID: 15310346 DOI: 10.1111/j.1365-2044.2004.03761.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient-maintained sedation using propofol has recently been shown to be effective for dental surgery. We compared this new technique to the established technique of operator administered midazolam. The two groups were compared before, during and after sedation. The two primary outcomes were time until discharge and oxygen saturation. Vital signs, anxiety and psychomotor skills were also compared. State anxiety was reduced to a greater extent in the propofol group (mean difference 10 (SD 4) mm; p = 0.010. Propofol patients recovered quicker (mean difference 7 (SD 1.4) min; p = 0.001). Propofol patients had a smaller reduction in arterial oxygen saturation (mean difference 0.8 (SD 0.3)%; p = 0.030), and a reduced increase in heart rate (mean difference 9 (SD 2) beats.min(-1); p < 0.001). Both techniques were well tolerated and safe. Propofol sedation offered superior anxiolysis, quicker recovery, less amnesia and less depression of simple psychomotor function.
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Affiliation(s)
- J A Leitch
- University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow, G2 3JZ, UK.
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Abstract
The agents used for sedation and analgesia during endoscopy have complex pharmacokinetic and pharmacodynamic properties. Knowledge of these characteristics is necessary for determining the proper agent and dose for specific patient needs. Short-acting agents, such as fentanyl, midazolam, and propofol, provide rapid sedation with a short duration of action that allows patients to return to normal functioning rapidly. When designing a dosing regimen with these agents, age and organ (liver, kidney) function of patients and concomitant medications that may interfere with metabolic and elimination pathways must be considered.
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Affiliation(s)
- Ed Horn
- Surgical Intensive Care Unit, Department of Pharmacy, The Johns Hopkins Hospital, 600 North Wolfe Street/Carnegie 180, Baltimore, MD 21287, USA.
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Abstract
BACKGROUND By using a small-diameter endoscope, EGD can be performed transnasally in adults. A prospective study was conducted to evaluate the feasibility of transnasal PEG placement without conscious sedation. METHODS Unsedated transnasal PEG was attempted in 23 patients by using a 5.9-mm-diameter videoendoscope. The indication for PEG insertion, success or failure, reason(s) for failure, and adverse effects of the procedure were recorded. During the first month, all patients were monitored by telephone contact for complications and to verify functionality of the PEG. RESULTS Transnasal PEG insertion was successful in 21 (91%) patients. The cause for failure was the inability to transilluminate the abdominal wall. Complications included epistaxis (n=1), minor wound infection (n=1), and soiling around the stoma (n=1). Of the 21 patients in whom transnasal PEG placement was successful, all were alive, with a functional gastrostomy at the 1-month follow-up. CONCLUSIONS Unsedated transnasal PEG tube insertion is minimally invasive, is feasible in daily practice in selected patients, and rarely is associated with complications.
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Affiliation(s)
- Jérôme Dumortier
- Department of Digestive Diseases, Hôpital Edouard Herriot, Lyon, France
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Campo R, Brullet E, Junquera F, Puig-Diví V, Vergara M, Calvet X, Marco J, Chuecos M, Sánchez A, Alcázar A, Ruiz M, Puig M, Real J. Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:503-7. [PMID: 15544734 DOI: 10.1016/s0210-5705(03)70516-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain). OBJECTIVE To evaluate the use of sedation in DEU in Catalonia. MATERIAL AND METHOD A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications. RESULTS Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation. CONCLUSIONS In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.
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Affiliation(s)
- R Campo
- Servicio de Aparato Digestivo, Corporació Parc Taulí, Sabadell, Barcelona, Spain.
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Ulmer BJ, Hansen JJ, Overley CA, Symms MR, Chadalawada V, Liangpunsakul S, Strahl E, Mendel AM, Rex DK. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clin Gastroenterol Hepatol 2003; 1:425-32. [PMID: 15017641 DOI: 10.1016/s1542-3565(03)00226-x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy. METHODS One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications. RESULTS The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5). CONCLUSIONS Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.
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Affiliation(s)
- Brian J Ulmer
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Hospital, Indianapolis 46202, USA
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Saruc M, Sertdemir A, Turkel N, Tuzcuoglu I, Ozden N, Yuceyar H. Midazolam-induced sedation for upper gastrointestinal endoscopy: assessment of endoscopist and patient satisfaction. Gastroenterol Nurs 2003; 26:164-7. [PMID: 12920432 DOI: 10.1097/00001610-200307000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Upper gastrointestinal endoscopy can be performed without intravenous sedation but the evidence suggests most patients and endoscopists prefer some form of premedication. Intravenous diazepam or midazolam are used by the majority of endoscopists in the United States, though it is not common practice in Turkey where this study was conducted. This study aimed to evaluate the efficacy and safety of midazolam in performing upper gastrointestinal endoscopy. A total of 352 patients undergoing upper gastrointestinal endoscopy were sedated with midazolam given as a bolus injection over 5 seconds. Ages of the patients ranged between 16 and 79 years (average: 41.6 +/- 12.7 years). The course of endoscopy, anterograde memory, degree of cooperation, degree of sedation, side effects, and acceptability of further intervention were evaluated by a questionnaire given to the patients and endoscopists.
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Affiliation(s)
- Murat Saruc
- Department of Gastroenterology, Endoscopy Unit, Celal Bayar University, Manisa, Turkey.
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Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc 2003; 57:198-204. [PMID: 12556784 DOI: 10.1067/mge.2003.59] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND EGD can be performed transnasally in adults by using small-diameter endoscopes. A large prospective study was conducted to evaluate the feasibility and tolerance of diagnostic transnasal EGD in daily practice. METHODS Unsedated transnasal EGD was attempted in 1100 consecutive patients, in 3 different institutions, by using a 5.9-mm or a 5.3-mm diameter endoscope. The operator determined whether the procedure was successful or unsuccessful, the reason for failures, and any side effects. The influence of gender, age, endoscope diameter, and type of topical anesthesia on the success or failure of the procedure was evaluated. Patients who previously had undergone peroral EGD were queried as to which procedure they preferred. RESULTS Transnasal EGD was feasible in 93.9% of the patients. The causes of failure were as follows: unsuccessful transnasal insertion (62.7%), patient refusal (19.4%), and nasal pain (17.9%). Female gender, young age (< or =35 years), and larger-endoscope diameter were significant predictive factors for procedure failure. Side effects included the following: epistaxis (2.3%), nasal pain (1.6%), and vaso-vagal reaction (0.3%). A majority (91%) of the patients who previously had undergone unsedated peroral EGD with a standard 9.8-mm diameter endoscope preferred transnasal EGD with a small-diameter endoscope. CONCLUSIONS Transnasal EGD is feasible in daily endoscopic practice and is preferred by patients. Side effects are rare.
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Affiliation(s)
- Jérôme Dumortier
- Department of Digestive Diseases, Hôpital Edouard Herriot, Lyon, France
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Leitch JA, Sutcliffe N, Kenny GNC. Patient-maintained sedation for oral surgery using a target-controlled infusion of propofol - a pilot study. Br Dent J 2003; 194:43-5. [PMID: 12540939 DOI: 10.1038/sj.bdj.4802412] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2002] [Accepted: 09/23/2002] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of a new patient-maintained propofol system for conscious sedation in dentistry. DESIGN Prospective clinical trial SETTING Department of Sedation, Glasgow Dental Hospital and School, 2001 SUBJECTS AND METHODS Patients scheduled for oral surgery with conscious sedation. Exclusions included ASA IV -V, inability to use the handset, opioid use and severe respiratory disease. INTERVENTIONS Patients were given intravenous propofol to a level of 1.0 microg/ml (reducing from 1.5 microg/ml) using a target controlled infusion system, they then controlled their sedation level by double-clicking a handset which on each activation increased the propofol concentration by 0.2 microg/ml. MAIN OUTCOME MEASURES Oxygen saturation, patient satisfaction, and surgeon satisfaction. RESULTS Twenty patients were recruited, 16 female and four male. Nineteen patients completed sedation and treatment successfully. Mean lowest oxygen saturation was 94%. No patients were over-sedated. All patients successfully used the system to maintain a level of sedation adequate for their comfort. Patient and surgeon satisfaction were consistently high. CONCLUSIONS Initial experience with this novel system has confirmed safety, patient satisfaction and surgeon satisfaction.
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Affiliation(s)
- J A Leitch
- Glasgow Dental Hospital and School, Glasgow.
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Abraham N, Barkun A, Larocque M, Fallone C, Mayrand S, Baffis V, Cohen A, Daly D, Daoud H, Joseph L. Predicting which patients can undergo upper endoscopy comfortably without conscious sedation. Gastrointest Endosc 2002; 56:180-9. [PMID: 12145594 DOI: 10.1016/s0016-5107(02)70175-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Eliminating conscious sedation for diagnostic endoscopy may be advantageous for patient safety and cost containment. The aim of this study was to identify and validate independent predictors of a comfortable, technically adequate, unsedated diagnostic upper endoscopy in Canadian patients. METHODS Patients were consecutively enrolled in a prospective fashion. Data collected on an initial cohort of 268 patients included demographics, a validated anxiety questionnaire, use of sedatives/analgesics, upper endoscopy experience, pharyngeal sensitivity, technical adequacy, and patient assessment of comfort after the procedure. The main outcome measure was "satisfactory upper endoscopy," a composite of optimal scores for patient comfort and technical adequacy. Univariate and multivariate analyses were performed to identify the optimal predictive model of a satisfactory unsedated diagnostic upper endoscopy. Once identified, 68 additional patients were enrolled in a similar fashion from an independent prospective sample for purposes of outcome validation. Multivariate analysis was then repeated with the total cohort (N = 336). These results were then compared for concordance with those obtained from the initial cohort. RESULTS Among the initial 268 patients (54.3% women; mean age 51 +/- 17 years), 49% were anxious, 15% regularly used sedatives and analgesics, 28% experienced increased pharyngeal sensitivity, and 41% had previously undergone upper endoscopy. Endoscopy was completed in 94.7% of patients without sedation and was technically adequate in 97%, and 80.1% were willing to repeat the procedure under similar conditions. Satisfactory upper endoscopy was achieved in only 59% of the initial cohort. The only independent and significant predictors of a satisfactory upper endoscopy were advancing age (OR 1.2: 95% CI [1.1, 1.4]) and decreased pharyngeal sensitivity (OR 0.5: 95% CI [0.27, 0.93]). Concordance of results were noted after validation with the second cohort. Satisfactory endoscopy was achieved in only 59.5% of the total cohort (n = 336); only 61% reported a comfortable procedural experience. CONCLUSIONS The proportion of patients who can comfortably undergo technically adequate unsedated upper endoscopy is modest. Unsedated upper endoscopy is most likely to be successful under these procedural conditions in patients of advancing age with decreased pharyngeal sensitivity. The generalizability of these findings to an American population requires further study and may assist in identifying a subgroup of patients in whom it is cost-effective to perform upper endoscopy comfortably without sedation.
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Affiliation(s)
- Neena Abraham
- The Division of Gastroenterology of the Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Sipe BW, Rex DK, Latinovich D, Overley C, Kinser K, Bratcher L, Kareken D. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc 2002; 55:815-25. [PMID: 12024134 DOI: 10.1067/mge.2002.124636] [Citation(s) in RCA: 226] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Propofol is under evaluation as a sedative for endoscopic procedures. METHODS Eighty outpatients (ASA Class I or II) undergoing colonoscopy were randomized to receive either propofol or midazolam plus meperidine, administered by a nurse and supervised by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychological function, and complications. RESULTS The mean dose of propofol administered was 218 mg; mean doses of midazolam and meperidine were, respectively, 4.7 mg and 89.7 mg. Mean time to sedation was faster in the propofol patients (2.1 min vs. 7.0 min; p < 0.0001), and depth of sedation was greater (p < 0.0001). On average, after the procedure, the propofol patients could stand at the bedside sooner (14.2 vs. 30.2 min), reached full recovery faster (14.4 vs. 33.0 min), and were discharged sooner (40.5 vs. 71.1 min) (all p < 0.0001). Patients who received propofol also expressed greater overall mean satisfaction on a 10-point visual analog scale (9.3 vs. 8.6; p < 0.05). At discharge, the propofol group had better scores on tests reflective of learning, memory, working memory span, and mental speed. Four patients in the midazolam/meperidine group developed minor complications (1 hypotension and bradycardia, 2 hypotension alone, and 1 tachycardia) and 1 patient in the propofol group had oxygen desaturation develop during an episode of epistaxis. CONCLUSION For outpatient colonoscopy, propofol administered by nurses and supervised by endoscopists has several advantages over midazolam plus meperidine and deserves additional investigation.
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Affiliation(s)
- Brian W Sipe
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis 46202, USA
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Catanzaro A, Faulx A, Pfau PR, Cooper G, Isenberg G, Wong RCK, Sivak MV, Chak A. Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients. Gastrointest Endosc 2002; 55:484-7. [PMID: 11923758 DOI: 10.1067/mge.2002.122576] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Esophagoscopy with a portable battery-powered endoscope could provide a safe, inexpensive, and minimally invasive way to screen for Barrett's esophagus or esophageal varices. The use of such an instrument in an unsedated fashion has not been previously evaluated. METHODS Patients referred for an EGD were recruited to undergo an additional examination with the battery-powered endoscope before EGD. In phase 1, (n = 42) patients received conscious sedation before the battery-powered endoscopic examination. In phase 2, (n = 56) patients were not sedated and were given the option of a peroral (n = 43) or transnasal (n = 13) endoscopy. Examiners were blinded to patient history and procedure indications. Esophageal findings, ease of intubation, optical quality, and patient comfort for the battery-powered endoscope and standard EGD were recorded by the endoscopist. RESULTS Ninety-eight patients (60 men, 38 women, mean age 53 years) were recruited. The sensitivity for detecting Barrett's esophagus, esophageal tumors, and esophageal varices was 54.5%, 66.7%, and 80%, respectively. Ease of intubation and patient comfort as perceived by the endoscopist were not significantly different between the battery-powered endoscope and EGD. Optical quality was ranked as less than 4 (on a 5-point scale with 5 = standard EGD and 1 = poor) in 42% of battery-powered endoscopic examinations. There were no complications. CONCLUSION The accuracy of esophageal examination with a 3.1-mm endoscope is substantially inferior to standard EGD. Thus, the battery-powered endoscope would not be useful for screening patients for Barrett's esophagus or varices unless improvements in optical quality and visualization are made.
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Affiliation(s)
- Andrew Catanzaro
- Division of Gastroenterology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44106-1736, USA
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Abstract
In the United States sedation and analgesia is the standard of practice when performing upper and lower gastrointestinal endoscopy. Many of these endoscopic procedures are performed in ambulatory endoscopy centers, including ambulatory surgery centers. This article reviews new Joint Commission on Accreditation of Healthcare Organizations standards for sedation and analgesia, drugs used for sedation and analgesia (including side effects), patient assessment and monitoring (before, during, and postprocedure), and discharge of patients from the ambulatory endoscopy center.
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Affiliation(s)
- Joseph J Vicari
- Department of Medicine, University of Illinois College of Medicine, 1601 Parkview Ave., Rockford, IL 6407, USA.
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Shaker R, Saeian K. Unsedated transnasal laryngo-esophagogastroduodenoscopy: an alternative to conventional endoscopy. Am J Med 2001; 111 Suppl 8A:153S-156S. [PMID: 11749942 DOI: 10.1016/s0002-9343(01)00852-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The introduction, refinement, and subsequent widespread use of flexible fiberoptic endoscopes have revolutionized the diagnosis and management of upper gastrointestinal (GI) disorders. There has been a simultaneous increase in the cost of managing upper GI disorders, which is in part attributed to the high price of endoscopy. Unfortunately, in the current cost-conscious health-care environment, the high cost of endoscopy has resulted in the underuse of this valuable clinical tool. Unsedated transnasal laryngo-esophagogastroduodenoscopy (T-EGD) is a new technique for upper endoscopy that uses an ultrathin endoscope and has a comparable yield to conventional upper endoscopy but obviates the need for conscious sedation because it is better tolerated. Studies have found that T-EGD is a feasible alternative to conventional endoscopy in terms of safety, efficacy, and cost containment. This article reviews these factors, the technique of T-EGD, patient and endoscopist considerations, tissue sampling, and the characteristics of ultrathin endoscopes used for T-EGD.
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Affiliation(s)
- R Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
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Gorelick AB, Inadomi JM, Barnett JL. Unsedated small-caliber esophagogastroduodenoscopy (EGD): less expensive and less time-consuming than conventional EGD. J Clin Gastroenterol 2001; 33:210-4. [PMID: 11500609 DOI: 10.1097/00004836-200109000-00008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A significant portion of the costs and complications of esophagogastroduodenoscopy (EGD) are related to the use of sedation. The feasibility and tolerability of small-caliber EGD (scEGD) without sedation has been evaluated; however, there is limited data concerning times and costs associated with this procedure as compared with conventional EGD (cEGD) with sedation. STUDY Sixteen patients underwent scEGD with the Pentax EG-1840 (outside diameter, 6 mm) without sedation. A control group of 16 patients was matched for age, sex, day, and indication of procedure. The time of procedure, time in procedure room, time in recovery room, and procedure costs were determined in both the study and control groups. After the procedure, scEGD patients completed surveys consisting of visual-analogue scales to assess tolerance and preference regarding sedation for future procedures. RESULTS Procedure time, procedure room time, and recovery room time was 5.2, 16.3, and 9 minutes for scEGD and 13.5, 34.9, and 41.3 minutes for cEGD, respectively (p < 0.001 for all comparisons). The mean cost of scEGD, excluding physician fees, was $462.00, which was significantly lower than the $587.00 for cEGD (p < 0.001). Survey results revealed good tolerance for the unsedated procedure. CONCLUSIONS Unsedated scEGD was well tolerated and resulted in a shorter time of procedure, less time spent in procedure room, reduced recovery room time, and lower costs as compared with cEGD with sedation.
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Affiliation(s)
- A B Gorelick
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Gillham MJ, Hutchinson RC, Carter R, Kenny GN. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc 2001; 54:14-7. [PMID: 11427835 DOI: 10.1067/mge.2001.116358] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND ERCP requires patient cooperation and often prolonged sedation. In different areas of anesthetic practice, patient-controlled sedation with a target-controlled infusion (TCI) of propofol provides effective sedation. The aim of this study was to assess the safety and efficacy of the same system in patients undergoing ERCP. METHODS Twenty patients used the TCI system. Patients received oxygen at 2 L/min via nasal cannulae. By using pharmacokinetic TCI software modeling, an initial propofol target blood concentration (Ct) of 1.0 microg/mL was supplemented on patient demand with a handset that, when pressed twice within 1 second, increased the Ct of propofol by 0.2 microg/mL. The maximum permissible target concentration was set at 3.0 microg/mL to prevent oversedation. RESULTS Sixteen patients used the system successfully throughout the procedure. The Ct propofol ranged from 1.2 to 2.6 microg/mL, and the number of successful handset activations (after commencement of the ERCP) ranged from 0 to 3. In 3 patients, the ceiling Ct propofol was attained without adequate sedation and the system was manually overridden. The system failed in 1 case because of patient confusion. There were no episodes of hemodynamic instability, airway obstruction, or significant oxygen desaturation. Endoscopist and patient satisfaction were high. Four patients were oversedated according to our criteria at the end of the procedure, but all were awake within 5 minutes of arrival in the recovery area. CONCLUSIONS Patient-maintained sedation with TCI propofol was safe and fully effective in 16 patients. Ease of endoscopy was rated high by the endoscopists, and all patients were well satisfied with their sedation. Adjustments to the software programming are being evaluated to increase the safety profile to avoid oversedation.
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Affiliation(s)
- M J Gillham
- University Department of Anaesthesia, Royal Infirmary, Glasgow, United Kingdom
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Abstract
Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.
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Affiliation(s)
- J J Farrell
- Harvard Medical School, Boston, Massachusetts, USA
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Laluna L, Allen ML, Dimarino AJ. The comparison of midazolam and topical lidocaine spray versus the combination of midazolam, meperidine, and topical lidocaine spray to sedate patients for upper endoscopy. Gastrointest Endosc 2001; 53:289-93. [PMID: 11231385 DOI: 10.1016/s0016-5107(01)70400-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Whether an opiate-benzodiazepine combination is superior to benzodiazepine alone for sedation in upper endoscopy is controversial. The purpose of this study was to compare the effectiveness of intravenous midazolam alone versus the combination of intravenous midazolam and intravenous meperidine for the sedation of patients undergoing upper endoscopy. METHODS One hundred seven patients scheduled for outpatient diagnostic esophagogastroduodenoscopy were randomly assigned to receive 50 mg intravenous meperidine (53 of 107) or placebo (54 of 107). All patients received topical lidocaine spray and as much midazolam as the endoscopist thought the patient needed. Patients and endoscopists were blinded as to assignment. Data collected included intubation time (seconds), procedure time (minutes), pulse, blood pressure, complications, and the need for reversal agents. The endoscopist evaluated the quality of sedation immediately after the procedure (1 = excellent, 2 = good, 3 = fair, and 4 = poor). The patient evaluated the procedure the next day by phone (1 = no discomfort or did not remember, 2 = slightly uncomfortable, 3 = extremely uncomfortable, and 4 = unacceptable). Patients were also asked whether they would agree to another esophagogastroduodenoscopy if their doctor thought it was medically necessary. RESULTS The intubation time, procedure time and blood pressure were not significantly different between the 2 groups. In comparing the meperidine group versus placebo group, the highest pulse (82.3 vs. 93.7, p = 0.0010), lowest pulse (67.2 vs. 72.3, p = 0.0194) and amount of midazolam used (4.0 vs. 4.8 mg, p = 0.0185 or 0.53 vs. 0.67 mg/kg, p = 0.0083) were significantly different by using a t test analysis. Patient evaluations comparing meperidine versus placebo showed responses of 1 (52 vs. 49), 2 (1 vs. 3), 3 (0 vs. 2) and 4 (0 vs. 0), which were not significantly different. The endoscopists'evaluation comparing meperidine versus placebo gave responses of excellent (44 vs. 27), good (6 vs. 22), fair (3 vs. 5) and poor (0 vs. 0), which were highly significantly different (p < 0.001) by using chi-square statistical techniques. CONCLUSION The addition of meperidine to midazolam in sedating patients undergoing upper endoscopy adds no benefit from the patient viewpoint, whereas endoscopists favored the use of both medications.
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Affiliation(s)
- L Laluna
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Al-Karawi MA, Sanai FM, Al-Madani A, Kfoury H, Yasawy MI, Sandokji A. Comparison of peroral versus ultrathin transnasal endoscopy in the diagnosis of upper gastrointestinal pathology. Ann Saudi Med 2000; 20:328-30. [PMID: 17322695 DOI: 10.5144/0256-4947.2000.328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- M A Al-Karawi
- Department of Gastroenterology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
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Fulton SA, Mullen KD. Completion of upper endoscopic procedures despite paradoxical reaction to midazolam: a role for flumazenil? Am J Gastroenterol 2000; 95:809-11. [PMID: 10710082 DOI: 10.1111/j.1572-0241.2000.01866.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Paradoxical excitation after benzodiazepine administration is well described. Although it is relatively uncommon, its occurrence can severely impede or even prevent the performance of upper endoscopy. We describe three cases in which paradoxical reactions to midazolam responded so well to flumazenil administration that the procedure was successfully completed in each instance. We review the limited literature on this topic and suggest that flumazenil may have greater utility in the management of this particular problem than is considered at present.
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Affiliation(s)
- S A Fulton
- Department of Internal Medicine, Case Western Reserve University at Metrohealth Medical Center, Cleveland, Ohio 44109-1998, USA
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Khan HA, Ahmad I, Ahmed W. Ventricular fibrillation after insertion of a self-expanding metallic stent for malignant dysphagia. Am J Gastroenterol 2000; 95:827. [PMID: 10710094 DOI: 10.1111/j.1572-0241.2000.01894.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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