Developments in flexible endoscopic surgery: a review

Establishing an anaesthetist-delivered propofol sedation service for advanced endoscopic procedures: implementing the RCA/BSG guidelines

BACKGROUND

Following recommendations from the Royal College of Anaesthetists and the British Society of Gastroenterology, we report our results of propofol sedation for complex endoscopic procedures delivered by a single consultant anaesthetist over a 5-year period.

METHODS

A weekly session was provided in the endoscopy department for procedures that were complex or could previously not be completed successfully. Deep sedation was provided by intermittent propofol bolus doses, supplemented with fentanyl where necessary, titrated to clinical effect. Patients were usually in semiprone or lateral positions and spontaneously breathed air supplemented with nasal oxygen. Service evaluation included patient recall, endoscopist satisfaction with conditions, procedural success and airway-related adverse outcomes.

RESULTS

We completed 1000 procedures, 42.5% of which were endoscopic retrograde cholangiopancreatography, with the remainder comprising a diverse range of endoscopic procedures of 3-156 min duration. Procedural conditions were excellent in 79% of cases, 261 procedures were completed which had been previously abandoned, 246 patients (24.6%) had a better experience than previously and none recalled any part of their procedure. Three patients required transient bag and mask ventilation, and nasal airways were used in 12 patients, but none required tracheal intubation or vasopressor support.

CONCLUSIONS

These guidelines facilitated a propofol sedation service with considerable benefits for patients and endoscopists. Provision of deep propofol sedation by an anaesthetist, in patients with an unsecured airway, appears practical, effective and efficient. Small adjustments to the airway were fairly common, but the incidence of adverse events and requirement for airway instrumentation was low.

Lowering the Barrier of Surgical Endoscopy With a Novel Articulating Retractor

Surgical endoscopy has gained traction over the past several decades as a viable option for therapeutic interventions in the gastrointestinal tract. It utilizes natural orifice access which shortens hospital stay, minimizes patient discomfort, and decreases overall healthcare costs. However, the inability to effectively retract and position target tissue is a significant limitation for these procedures. Current instruments are unable to triangulate and can only be manually withdrawn or advanced through the channels. There is a need to provide better access and control of soft tissue to be able to perform more complex and complete endoscopic resections. We have developed a novel device to provide optimal tissue retraction for endoscopic procedures. Our device consists of an articulating tissue retractor and a specialized handle. Two articulating curves were created that can manipulate the position and direction of the retractor tip. Each curve is independently adjusted by locking thumb sliders, allowing for increased range of motion and retraction independent of endoscope position. With a diameter of 2.8 mm, the proposed device can be used in current endoscopic equipment. Preliminary testing showed that our retractor has comparable slip strength to a commercially available device (1.13 N ± 0.53 N versus 1.10 N ± 0.51 N, p-value: 0.416), but has much greater range of motion (maximum deflection of 72 deg compared to 0 deg). This increased range of motion allows the articulating grasper to better triangulate and preserve visualization of the dissection plane, allowing it to overcome the most significant barrier restricting endoscopic surgery.