Sedation in gastrointestinal endoscopy: Current issues

Comparative efficacy and safety of nalbuphine and hydromorphone in painless colonoscopy techniques: a randomized controlled trial

BACKGROUND

Colonoscopy is essential for diagnosing colon lesions but is often associated with discomfort. Painless colonoscopy techniques are being increasingly used to improve the patient experience."However, in the case of painless colonoscopy, anesthesia is performed outside the operating room, which requires more significant peri-examination of hemodynamic changes and adverse postoperative reactions. This requires a more careful selection of narcotic analgesics, and there needs to be optimal analgesic drug guidance in clinical practice. This study compared the efficacy and safety of nalbuphine and hydromorphone in improving patient comfort and maintaining hemodynamic stability during elective colonoscopy.

METHODS

This prospective, randomized, double-blinded controlled trial included 72 adult patients (aged 18-65) who underwent sedation colonoscopy. The 72 patients were randomly divided into two groups using a computer-generated random sequence. Body mass index 18.5-28.0 kg/m2; American Society of Anesthesiologists (ASA) grade I to II. Then, the nalbuphine group was given 0.13 mg/kg nalbuphine, the hydromorphone group was given 0.016 mg/kg hydromorphone, and during the operation, 10-20 mg/time propofol could be appropriately injected according to the patient's examination and cooperation. All patients were continuously monitored for oxygen saturation, heart rate, and noninvasive mean arterial blood pressure. The colonoscopy time and anesthesia time were recorded. Adverse reactions such as hypotension, decreased oxygen saturation, nausea, and vomiting were recorded. Anesthesiologist satisfaction, gastroenterologist (operator), and patient satisfaction were recorded.

RESULTS

Both nalbuphine and hydromorphone effectively maintained hemodynamic stability, with no significant differences in vital signs observed between the groups (P > 0.05). However, nalbuphine significantly reduced the incidence of postoperative nausea, vomiting, dizziness, and headache compared to hydromorphone (P < 0.05). The reduced side effects of nalbuphine were marked, suggesting a better postoperative comfort profile.

CONCLUSIONS

While nalbuphine and hydromorphone effectively maintain intraoperative vital signs, nalbuphine offers superior postoperative comfort. This makes nalbuphine a preferable analgesic choice in outpatient colonoscopy settings. Further research is warranted to determine the optimal dosages for both drugs and to explore their mechanisms of action in procedural pain management.

REGISTER NUMBER

ChiCTR2300077446,November 9, 2023.

Efficacy and safety of remimazolam for sedation during endoscopic procedures in Japanese: A prospective phase III clinical trial

OBJECTIVES

Remimazolam is a general anesthetic with a short elimination half-life and its pharmacokinetics are less affected by liver and kidney function. It may be useful for sedation during endoscopic procedures in patients. This single-arm clinical trial aimed to evaluate the efficacy and safety of remimazolam for sedation in patients undergoing endoscopic procedures.

METHODS

Patients undergoing endoscopic procedures were included in this study. Remimazolam was administered intravenously with opioid analgesics, and the endoscopic procedure was started after an efficient level of sedation (Modified Observer's Assessment of Alertness/Sedation score ≤3) was achieved. The primary end-point for efficacy was the sedation success rate during the endoscopic procedures. Data on adverse events were collected for safety evaluation.

RESULTS

Sixty-two patients were included in the analysis. The sedation success rate of 93.5% (84.3-98.2%) exceeded the threshold success rate of 80% (P = 0.004). In all, 98.4% of patients were appropriately sedated before endoscope insertion. The median time from the first dose of remimazolam to achieving sedation was 4.0 min, while the median time from the end of the endoscopic procedure to being deemed ready to leave the room was 2.0 min. Adverse events were observed in 22 cases (35.5%). The severity of adverse events was moderate in five cases (8.1%), mild in 17 cases (27.4%), and there was no severe case.

CONCLUSION

Sedation with remimazolam plus opioid analgesics was effective and well tolerated, regardless of endoscopic procedure site. These findings suggest that remimazolam is a useful sedative during endoscopic procedures.

Comparison of sedation with pentazocine or pethidine hydrochloride for endoscopic ultrasonography in outpatients: A single-center retrospective study

Objectives

Endoscopic ultrasonography (EUS) plays an important role in the diagnosis of pancreatobiliary diseases. However, an appropriate sedation method for EUS has not been established. Therefore, this study aimed to examine the safety and complications of sedation with pentazocine or pethidine hydrochloride for outpatient diagnostic EUS.

Methods

We retrospectively reviewed 1302 consecutive cases in our department that underwent outpatient diagnostic EUS between April 2019 and September 2021. Until June 2020, EUS was performed under sedation with midazolam and pentazocine (pentazocine group) in principle; after June 2020, sedation with midazolam and pethidine hydrochloride (pethidine hydrochloride group) was used. A cohort of patients with comparable backgrounds was identified using propensity score matching.

Results

A total of 486 cases were included in this study. Sedation-related adverse events during the endoscopic procedures were not significantly different between the groups. The median time spent in the recovery room after EUS was significantly shorter in the pethidine hydrochloride group than in the pentazocine group (69 versus vs. 77 min; p < 0.001). The frequency of nausea or vomiting after EUS was significantly lower in the pethidine hydrochloride group than in the pentazocine group (0% [0/486] vs. 6.2% [29/486]; p < 0.001). The frequency of readmission to the recovery room after discharge was significantly lower in the pethidine group than in the pentazocine group (0 [0%] vs. 18 [3.7%], respectively; p < 0.001).

Conclusions

The combination of midazolam and pethidine hydrochloride is a more favorable anesthetic than the combination of midazolam and pentazocine for diagnostic EUS in outpatients.

Bilevel positive airway pressure ventilation to prevent hypoxaemia during gastroscopy under sedation in patients at risk of hypoxaemia: study protocol for a prospective randomised controlled trial

INTRODUCTION

During sedation for gastroscopy, hypoxaemia represents the most common adverse event. The objective of this trial is to assess the efficacy and safety of bilevel positive airway pressure (BPAP) for the prevention of hypoxaemia, in comparison with nasal cannula oxygen therapy, among patients predisposed to hypoxaemia during sedation for gastroscopy.

METHODS AND ANALYSIS

This randomised controlled trial (RCT) will include 616 patients at risk of hypoxaemia when undergoing gastroscopy, including those with advanced age, frailty, American Society of Anesthesiologists grades III-IV, obesity, obstructive sleep apnoea-hypopnoea syndrome, cardiac disease, respiratory disease and diabetes. The patients will be randomly assigned to either the BPAP or nasal cannula group in a 1:1 ratio. The primary analysis for this study will use the modified intention-to-treat analysis set. The primary outcome is defined as the incidence of hypoxaemia (SpO275%-90%, duration 5-60 s). Outcomes data will be compared using the χ2 or Fisher's exact tests. Effect sizes will be used to assess the clinical effects of the intervention using absolute risk differences and 95% CIs. To assess the efficacy of BPAP in different patient subgroups, analyses will be performed based on clinical characteristics and risk factors associated with hypoxaemia.

ETHICS AND DISSEMINATION

The Ethics Committee of the First Affiliated Hospital of Zhengzhou University reviewed and approved this RCT (Scientific Research Ethics Review: 2023-KY-0815-003). Subsequently, the outcome will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2400084596.

Efficacy and Safety of Remimazolam in Short Endoscopic Procedures: A Systematic Review and Meta-Analysis

Background and Objectives: Appropriate sedation and anesthesia are crucial for ensuring comfortable endoscopic procedures. Propofol is one of the most often used sedatives. However, its safety and adverse effects restrict its usage. Remimazolam is a relatively new intravenous benzodiazepine that offers many benefits. Our analysis aims to evaluate the effectiveness and safety of remimazolam during short endoscopic procedures. Materials and Methods: We conducted a comprehensive search of the PubMed, Web of Science, ClinicalTrials.gov, and Turning Research Into Practice databases up to 31 December 2023, for randomized controlled trials published in English. Statistical analyses were performed using Cochrane Review Manager 5.4.1 and Stata Software/MP. Results: The success rate of sedation with remimazolam was slightly lower than that with propofol (RR: 0.99, 95% CI: 0.98~1.00; p = 0.004; I2 = 42%). As for anesthetic effect-related outcomes, remimazolam did not show advantages in onset time (MD = 12.72, 95% CI: 6.53~18.90, p < 0.001, I2 = 94%), recovery time (MD = 0.86, 95% CI: -0.55~2.27, p = 0.23, I2 = 98%), or intraoperative body movement (RR: 1.18, 95% CI: 0.60~2.32, p = 0.62, I2 = 87%). However, compared to propofol, remimazolam significantly reduced the incidence of several adverse events, including injection pain (RR: 0.07, 95% CI: 0.03~0.14, p < 0.001, I2 = 69%), intraoperative hypotension (RR: 0.38, 95% CI: 0.31~0.47, p < 0.001, I2 = 65%), bradycardia (RR: 0.25, 95% CI: 0.15~0.45, p < 0.001, I2 = 0%), and respiratory depression (RR: 0.34, 95% CI: 0.25~0.46, p < 0.001, I2 = 50%). The incidence of postoperative nausea and vomiting (PONV) was slightly higher with remimazolam (RD: 0.01, 95% CI: 0.00~0.03, p = 0.04, I2 = 33%). Conclusions: Remimazolam is a promising sedative for short endoscopic procedures due to its superior safety profile despite a slightly lower sedation success rate compared to propofol.

Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial

BACKGROUND

Propofol has been widely used in bidirectional gastrointestinal endoscopy sedation; however, it frequently leads to cardiovascular adverse events and respiratory depression. Propofol target-controlled infusion (TCI) can provide safe sedation but may require higher dosages of propofol. On the contrary, etomidate offers hemodynamic stability.

AIM

To evaluate the effect of different dose etomidate added to propofol TCI sedation during same-visit bidirectional endoscopy.

METHODS

A total of 330 patients from Fujian Provincial Hospital were randomly divided into three groups: P, 0.1EP, and 0.15EP. Patients in the P group received propofol TCI only, with an initial effect-site concentration of the propofol TCI system of 3.0 mg/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 and 0.15 mg/kg etomidate intravenous injection, respectively, followed by propofol TCI.

RESULTS

Patients in the 0.15EP group had higher mean blood pressure after induction than the other groups (P group: 78 mmHg, 0.1EP group: 82 mmHg, 0.15EP group: 88 mmHg; P < 0.05). Total doses of propofol consumption significantly decreased in the 0.15EP group compared with that in the other groups (P group: 260.6 mg, 0.1EP group: 228.1 mg, 0.15EP group: 201.2 mg; P < 0.05). The induction time was longer in the P group than in the other groups (P group: 1.9 ± 0.7 minutes, 0.1EP group: 1.2 ± 0.4 minutes, 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group than in the other groups (P group: 4.8 ± 2.1 minutes, 0.1EP group: 4.5 ± 1.6 minutes, 0.15EP group: 3.9 ± 1.4 minutes; P < 0.01). The incidence of hypotension (P group: 36.4%, 0.1EP group: 29.1%, 0.15EP group: 11.8%; P < 0.01) and injection pain was lower in the 0.15EP group than in the other groups (P < 0.05). Furthermore, the incidence of respiratory depression was lower in the 0.15EP group than in the P group (P < 0.05). Additionally, the satisfaction of the patient, endoscopist, and anesthesiologist was higher in the 0.15EP group than in the other groups (P < 0.05).

CONCLUSION

Our findings suggest that 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, along with higher patient, endoscopist, and anesthesiologist satisfaction.

Characteristics of cases for which esophageal endoscopic submucosal dissection under general anesthesia is recommended

BACKGROUND/AIMS

Esophageal endoscopic submucosal dissection (ESD) performed under general anesthesia can potentially provide more stable treatment in difficult cases than that under sedation. We evaluated the clinical characteristics and outcomes of ESD performed under general anesthesia compared with those under propofol sedation and discussed the cases in which general anesthesia is recommended.

PATIENTS AND METHODS

In total, 292 lesions in 265 consecutive patients undergoing esophageal ESD at Yamaguchi University Hospital from 2013 to 2023 were included in this retrospective study.

RESULTS

ESD was performed under general anesthesia for 92 lesions in 81 patients and under propofol sedation for 200 lesions in 184 patients. Tumor long-axis diameter was larger (39.8 ± 14.4 mm vs. 32.4 ± 9.9 mm, p < 0.01) and dissection speed was faster (10.5 ± 5.9 mm2/min vs. 7.5 ± 4.2 mm2/min, p < 0.01) in the general anesthesia group versus the sedation group. In the sedation group, a treatment history of pharyngeal cancer was significantly associated with a slower dissection speed (p = 0.037). The sedation group showed higher frequencies of hypoxemia (0% vs 9.8%, p < 0.01), interruption due to body movement (0% vs 13%, p < 0.01), and acute adverse events (21.7% vs 33.5%, p = 0.05). A treatment history of pharyngeal cancer was shown to be the significant factor contributing to acute adverse events (p = 0.018).

CONCLUSION

Esophageal ESD under general anesthesia can be a treatment option in patients with difficulty in performing stable procedures with propofol sedation. Especially in patients with a treatment history of pharyngeal cancer in whom ESD is more difficult to be performed and who are at higher risk for acute adverse events, general anesthesia can be considered.

Application of a novel gastro-laryngeal mask in upper gastrointestinal endoscopy surgery: A pilot randomized clinical trial

BACKGROUND

The Gastro-Laryngeal Mask (Jcerity Endoscoper™ Airway) is a new airway management technique utilized in patients undergoing upper gastrointestinal endoscopy surgery under general anesthesia, but evidence of its effectiveness and safety is scarce.

OBJECTIVE

To assess the success rate of insertion, cardiovascular response, airway pressure, time taken for placement, nausea or vomiting, pharyngodynia, and other complications of using the new type of back-open gastroscopy laryngeal mask.

METHODS

We screened 1401 patients; 105 were ineligible, and 40 declined to participate. Participants were randomly allocated into the Jcerity Endoscoper™ Airway (JEA) group and the endotracheal tube (ET) group. Among them, 1266 patients were randomly assigned to receive endotracheal intubation (n = 633) or JEA (n = 633).

RESULTS

Compared with the ET group, the JEA group had a significantly shorter insertion time and less cardiovascular response during insertion. The time taken for extubation after anesthesia and residence time in PACU in the JEA group was shorter than in the ET group. Especially, the incidence of pharyngodynia in the JEA group was lower than that in the ET group. The satisfaction of endoscopists with the JEA reached 99.4%.

CONCLUSIONS

This study showed that the back-open JEA can not only provide a safe and effective airway guarantee for patients but also provide convenience for gastroenterologists to carry out endoscopic operations.

TRIAL REGISTRATION

The trial was registered before patient enrollment at the Chinese Clinical Trial Registry Center (ChiCTR2100046864, principal investigator: Yunqi Lv, date of registration: 2021-05-29). The study was conducted in the painless diagnosis and treatment center of the First Affiliated Hospital of Zhengzhou University from June 2021 to October 2023 (Date of enrolment of the first research participant:2021-06-01).

Comparative Study of Remimazolam and Midazolam During Sedated Upper Gastrointestinal Endoscopy: A Propensity Score Matching Analysis

AIM

This study aimed to compare the use of remimazolam and midazolam in upper gastrointestinal endoscopy in Japan as a sub-analysis of data from an investigator-initiated clinical trial of remimazolam.

METHODS AND RESULTS

Patients in two groups were matched using propensity score matching. We evaluated the time from the end of the gastrointestinal endoscopy until discharge, the time from the end of the procedure until awakening, and adverse events. Overall, 36 participants from the clinical trial population who underwent upper gastrointestinal endoscopy using remimazolam and 199 patients who underwent the procedure with midazolam during the same period were included in this study. Following propensity score matching, 34 patients in both groups were matched. The median time from the end of the procedure until awakening was 27.0 min (23.0-40.5 min) in the midazolam group (Group M) and 0 min (0-5.0 min) in the remimazolam group (Group R); the median time from the end of the upper gastrointestinal endoscopy until discharge was 39.0 min (35.0-52.5 min) in Group M and 5.0 min (0-5.0 min) in Group R (p < 0.01). Reported adverse events were hypotension and hypoxemia in one patient in Group R.

CONCLUSION

Compared with midazolam, remimazolam significantly shortened the time to patient awakening and duration until the patient could leave the endoscopy room. Trial Registration: The main study (REM-IICT JP1) is registered with the Japan Registry of Clinical Trails: jRCT2031200360.

Deep Sedation in High-risk Patients Undergoing Emergency Upper GI Endoscopy: A Retrospective Study Assessing Safety and Effectiveness

Introduction

Emergency upper gastrointestinal (GI) endoscopy is often prolonged and complex, performed during high-risk conditions. These procedures can be affected by an increased risk for airway compromise. Scarce literature can be found providing guidance on anesthesiological conduct during upper GI endoscopy in Emergency.

Methods

This was a monocentric retrospective study conducted on 96 patients treated in the Emergency Gastroenterology Unit at AORN Cardarelli, between June and October 2023. Key features of moderate and deep sedation procedures were investigated.

Results

There was no statistically significant difference in the incidence of complications and respiratory depression between the patients receiving moderate sedation versus those treated with deep sedation.

Discussion

Adverse outcomes of sedation and analgesia during endoscopic procedures are rare, even during a deep state of sedation.

Nasal mask versus conventional oxygen supply for endoscopy under intravenous sedation: protocol for a systematic review and meta-analysis

INTRODUCTION

Hypoxaemia is a frequent complication associated with endoscopy conducted under intravenous sedation, highlighting the need for effective and practical interventions. This systematic review aims to evaluate the effectiveness of nasal mask oxygenation in reducing the incidence of hypoxaemia during endoscopy under intravenous sedation compared with the conventional oxygen supply.

METHODS AND ANALYSIS

This study strictly adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines. PubMed, Embase, Cochrane Library, Web of Science and China National Knowledge Infrastructure databases will be electronically searched from their inception to May 2024 to identify randomised controlled trials comparing a nasal mask with conventional oxygen supply for endoscopy under intravenous sedation. The study selection, data extraction and quality assessment processes will be conducted independently by two reviewers. The risk of bias in the included studies will be assessed using the Cochrane Risk of Bias Tool for Randomized Trials, and the strength of evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation guidelines. The meta-analysis will be performed using STATA V.16.0, with effect sizes calculated using the standardised mean difference and 95% CI. Heterogeneity will be assessed using Cochran's Q statistics, and inconsistency will be measured using I2 statistics. Potential sources of bias will also be evaluated.

ETHICS AND DISSEMINATION

The data used for this systematic review will be exclusively extracted from published studies. Additional ethical approval and informed consent are not required. This systematic review will be published in a peer-reviewed journal and will be presented at conferences and congresses.

PROSPERO REGISTRATION NUMBER

CRD42024545231.

Acupuncture reduces sedative and anaesthetic consumption and improves pain tolerance in patients undergoing colonoscopy: a Meta-analysis

OBJECTIVE

To evaluate the effects of acupuncture anesthesia on the consumption of sedatives and anesthetics, pain, and time consumption in patients undergoing colonoscopy, thus providing evidence that acupuncture anesthesia should be extended to endoscopists and anesthetists.

METHODS

Four English and four Chinese databases were searched for randomised controlled trials of acupuncture anaesthesia in patients undergoing colonoscopy, published from database inception to 1 March 2023. Outcomes were consumption of sedatives and anaesthetics, pain tolerance, visual analog scale (VAS) score, the meantime consumption of examination, satisfaction, and adverse reactions.

RESULTS

Thirty-one randomized controlled trials with a total of 4790 participants were included. Results showed that acupuncture anaesthesia significantly reduced consumption of sedatives and anaesthetics [9 studies, n = 944, standardized mean difference (SMD) = －0.82, 95% CI (－1.31, －0.33), P = 0.001], VAS score [9 studies, n = 1790, mean difference (MD) = －1.13, 95% CI (－1.70, －0.57), P < 0.001], meantime consumption [21 studies, n = 3799, MD = －2.09, 95% CI (－3.15, －1.03), P<0.001] and adverse reactions of colonoscopy [7 studies, n = 738, odds ratio (OR) = 0.17, 95% CI (0.10, 0.28), P<0.001]. Acupuncture also significantly improved pain tolerance [14 studies, n = 1661, OR = 7.05, 95% CI (3.79, 13.12), P<0.001], while no beneficial effects were found for satisfaction [7 studies, n = 843, SMD = 0.02, 95% CI (－0.38, 0.43), P = 0.91].

CONCLUSION

Acupuncture has beneficial effects on patients undergoing colonoscopy, particularly in reducing consumption of sedatives and anaesthetics, alleviating pain, shortening the time consumption of examination and preventing adverse events. As an alternative, effective, inexpensive, and accessible approach, acupuncture anaesthesia should be extended to endoscopists and anaesthesiologists.

Development of a predictive model for hypoxia due to sedatives in gastrointestinal endoscopy: a prospective clinical study in Korea

BACKGROUND/AIMS

Sedation has become a standard practice for patients undergoing gastrointestinal (GI) endoscopy. However, considering the serious cardiopulmonary adverse events associated with sedatives, it is important to identify patients at high risk. Machine learning can generate reasonable prediction for a wide range of medical conditions. This study aimed to evaluate the risk factors associated with sedation during GI endoscopy and develop a predictive model for hypoxia during endoscopy under sedation.

METHODS

This prospective observational study enrolled 446 patients who underwent sedative endoscopy at the Korea University Ansan Hospital. Clinical data were used as predictor variables to construct predictive models using the random forest method that is a machine learning algorithm.

RESULTS

Seventy-two of the 446 patients (16.1%) experienced life-threatening hypoxia requiring immediate medical intervention. Patients who developed hypoxia had higher body weight, body mass index (BMI), neck circumference, and Mallampati scores. Propofol alone and higher initial and total dose of propofol were significantly associated with hypoxia during sedative endoscopy. Among these variables, high BMI, neck circumference, and Mallampati score were independent risk factors for hypoxia. The area under the receiver operating characteristic curve for the random forest-based predictive model for hypoxia during sedative endoscopy was 0.82 (95% confidence interval, 0.79-0.86) and displayed a moderate discriminatory power.

CONCLUSIONS

High BMI, neck circumference, and Mallampati score were independently associated with hypoxia during sedative endoscopy. We constructed a model with acceptable performance for predicting hypoxia during sedative endoscopy.

Optimizing sedation in gastroscopy: a study on the etomidate/propofol mixture ratio

Objective

Propofol and etomidate are the most commonly used sedative agents in procedural sedation, each with its own advantages and disadvantages. However, there remains considerable controversy regarding the optimal ratio for the mixture of these two drugs, warranting further investigation. Therefore, this study aims to investigate the optimal ratio for combining propofol and etomidate during gastroscopy.

Methods

This study is a prospective, double-blinded, randomized controlled clinical trial. One hundred and sixty-two patients from July 2019 to December 2022 were evenly classified into three groups using a random number table as follows: (1) P group (propofol); (2) EP1 group (5 mL etomidate +10 mL propofol); (3) EP2 group (10 mL etomidate +10 mL), 54 patients per group. The medications, including a pre-sedation dose of 50 μg/kg dezocine followed by sedatives, ceasing when the patient's eyelash reflex vanished, indicating adequate sedation. Mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2) measurements taken before anesthesia (T1), immediately after the administration of sedatives (T2), immediately gastroscopic insertion (T3) and immediately recovery (T4) were determined. Additional, perioperative related outcomes and adverse events were also recorded.

Results

The EP2 group exhibited a higher MAP at T2 compared to the P and EP1 groups (p < 0.05). Calculated decreases in MAP revealed values of 19.1, 18.8, and 13.8% for the P, EP1, and EP2 groups at T2, respectively. Adverse events: Group EP2 exhibited a significantly lower hypotension incidence (11.1%) compared to the Propofol group (50%) and EP1 (31.5%). Concerning injection pain, Group EP2 also showing a significant decrease in comparison to P and EP1 groups (p < 0.05).

Conclusion

The use of a mixture of 10 mL etomidate and 10 mL propofol (at a 1:1 ratio) combined with dezocine for painless gastroscopy demonstrates hemodynamic stability, a low incidence of adverse reactions.

Clinical Trial Registration

https://www.chictr.org.cn/showproj.html?proj=39874.

Comparing Patient Comfort During Bronchoscopy Under Conscious Sedation and Monitored Anesthesia Care: A Prospective, Observational, Controlled Study

BACKGROUND

Flexible bronchoscopy (FB) often involves sedation, with the choice left to the bronchoscopist's discretion. Prior research on sedation in gastroscopic endoscopies yields conflicting information regarding the preferred method for FB. This study compares patient comfort levels during bronchoscopy with mindful sedation using fentanyl, nalbuphine, and midazolam versus monitored anesthesia care (MAC) using propofol, midazolam, and ketamine.

METHODS

This prospective observational study assessed 83 patients undergoing bronchoscopy under either conscious sedation (CS) (n=40) or MAC (n=43). Patient comfort, sedation levels, emotional state, recovery time, safety, and the impact of smoking history and comorbidities were evaluated. Data collection included direct patient questioning and observation using the Modified Observed Assessment of Alertness and Sedation (MOAA/S) form.

RESULTS

Comfort levels were similar between groups, with mean scores of 3.6±0.89 for CS and 3.3±0.54 for MAC. MAC induced deeper sedation (mean scores: 4.37±0.66 vs. 3.8±0.98). Recovery time and complications were comparable. Emotional states and medical history did not significantly differ between groups.

CONCLUSION

CS is not inferior to MAC for bronchoscopy, providing comparable comfort and safety with less intense sedation and lower cost. These findings support the use of CS for bronchoscopy procedures, offering a cost-effective alternative without compromising patient comfort or safety.

Deep learning assists detection of esophageal cancer and precursor lesions in a prospective, randomized controlled study

Endoscopy is the primary modality for detecting asymptomatic esophageal squamous cell carcinoma (ESCC) and precancerous lesions. Improving detection rate remains challenging. We developed a system based on deep convolutional neural networks (CNNs) for detecting esophageal cancer and precancerous lesions [high-risk esophageal lesions (HrELs)] and validated its efficacy in improving HrEL detection rate in clinical practice (trial registration ChiCTR2100044126 at www.chictr.org.cn). Between April 2021 and March 2022, 3117 patients ≥50 years old were consecutively recruited from Taizhou Hospital, Zhejiang Province, and randomly assigned 1:1 to an experimental group (CNN-assisted endoscopy) or a control group (unassisted endoscopy) based on block randomization. The primary endpoint was the HrEL detection rate. In the intention-to-treat population, the HrEL detection rate [28 of 1556 (1.8%)] was significantly higher in the experimental group than in the control group [14 of 1561 (0.9%), P = 0.029], and the experimental group detection rate was twice that of the control group. Similar findings were observed between the experimental and control groups [28 of 1524 (1.9%) versus 13 of 1534 (0.9%), respectively; P = 0.021]. The system's sensitivity, specificity, and accuracy for detecting HrELs were 89.7, 98.5, and 98.2%, respectively. No adverse events occurred. The proposed system thus improved HrEL detection rate during endoscopy and was safe. Deep learning assistance may enhance early diagnosis and treatment of esophageal cancer and may become a useful tool for esophageal cancer screening.

Safety and efficacy comparison of remimazolam and propofol for intravenous anesthesia during gastroenteroscopic surgery of older patients: A meta-analysis

BACKGROUND

Remimazolam is characterized by rapid action and inactive metabolites. It is used as the general anesthetic for many clinical surgeries. In this study, we performed a meta-analysis to evaluate whether remimazolam is superior to propofol for gastroenteroscopy in older patients.

AIM

To compare the adverse events and efficacy of remimazolam and propofol during gastroenteroscopy in older adults.

METHODS

The PubMed, Web of Science, the Cochrane Library databases were queried for the relevant key words "remimazolam," "and propofol," "and gastrointestinal endoscopy or gastroscopy." The search scope was "Title and Abstract," and the search was limited to human studies and publications in English. Seven studies wherein remimazolam and propofol were compared were included for the meta-analysis.

RESULTS

We selected seven randomized controlled trials involving 1445 cases for the analysis. Remimazolam reduced the hypotension (relative risk, RR = 0.44, 95%CI: 0.29-0.66, P = 0.000), respiratory depression (RR = 0.46, 95%CI: 0.30-0.70, P = 0.000), injection pain (RR = 0.12, 95%CI: 0.05-0.25, P = 0.000), bradycardia (RR = 0.37, 95%CI: 0.24-0.58, P = 0.000), and time to discharge [weighted mean difference (WMD) = -0.58, 95%CI: -0.97 to -0.18, P = 0.005], compared to those after propofol administration. No obvious differences were observed for postoperative nausea and vomiting (RR = 1.09, 95%CI: 0.97-1.24, P = 0.151), dizziness (RR = 0.77, 95%CI: 0.43-1.36, P = 0.361), successful sedation rate (RR = 0.96, 95%CI: 0.93-1.00, P = 0.083), or the time to become fully alert (WMD = 0.00, 95%CI: -1.08-1.08, P = 0.998).

CONCLUSION

Remimazolam appears to be safer than propofol for gastroenteroscopy in older adults. However, further studies are required to confirm these findings.

Assessing wound complications in gastroscopy with Streptomyces protease enzyme combined with Shutai

Current gastroscopy practices necessitate a balance between procedural efficiency and patient safety. It has been hypothesized that increasing procedure outcomes through the use of Streptomyces protease enzyme and Shutai is possible; however, precise nature of any potential adverse reactions and complications remains unknown. In Zhanjiang, China, 213 patients undergoing gastroscopy participated in this controlled trial. The subjects were allocated at random into two groups: control and treatment. The treatment group was administered topical Streptomyces protease enzyme and intravenous Shutai. Using chi-square and t-tests, information regarding patient demographics, adverse reactions, wound healing, procedure duration, distress levels, and satisfaction was gathered and analysed. The demographic and medical history characteristics of the groups were comparable. There was a greater prevalence of modest immediate reactions in the treatment group (p < 0.05), whereas there were no significant variations observed in delayed reactions and long-term complications (p > 0.05). The treatment group exhibited superior efficiency metrics, including shorter durations for diagnosis, procedure completion and recuperation (p < 0.05). The treatment group exhibited significantly higher patient satisfaction scores (p < 0.05). The incorporation of Streptomyces protease enzyme and Shutai into gastroscopy procedures resulted in significantly enhanced level of procedural efficacy and patient contentment while not introducing an additional risk of long-term complications. The increase in moderate immediate reactions that have been observed requires additional research in order to determine their clinical significance. Although these agents present a possible progression in the field of gastroscopy, their application should be tempered by the immediate adverse reactions that have been documented.

Propofol Sedation in Pediatric Upper Endoscopy: A Study of Pharmacodynamics and the Effects of Gastroenterologists, Anesthesiologists, and Supervised Participants on the Procedure Time and Sedation Time

Background and aims Propofol combined with fentanyl is a commonly used sedative for pediatric upper endoscopies (UEs). The primary aim was to study the association between propofol dose and procedure and sedation time. The secondary aims were to assess the pharmacodynamics of propofol use with fentanyl and evaluate if gastroenterologists' and anesthesiologists' years of experience or the presence of supervised participants (such as students, residents, and fellows) have any influence on the procedure and sedation time. Methods A retrospective study was performed at the Children's Hospital of Michigan on patients under 18 years who underwent UEs with propofol sedation with fentanyl over a two-year period. Results A correlation was found between the propofol amount used expressed per body mass index (BMI)/body surface area (BSA), procedure time, and sedation time (p < 0.0001). Throat pain was the most common post-procedural adverse event (4.48%). The impact of psychoactive drugs on these events was not statistically significant, but attention-deficit/hyperactivity disorder (ADHD) medication use was related to increased post-procedural pain complaints. The use of prescribed psychoactive medications was associated with larger propofol dose usage (p = 0.007) without a significant increase in sedation time. Individual gastroenterologists, their years of experience, and the presence of supervised participants were associated with different procedure times (p <0.0001, <0.0001, 0.01). Fellow participation was associated with a 1.11-minute procedure time increase (p = 0.04). Individual anesthesiologists, their years of experience, and the presence of supervised participants were associated with different sedation times (p <0.0001, <0.0001, 0.01). Conclusion We found a novel correlation between propofol dosing expressed by the BMI/BSA and sedation time. The UE procedure time and sedation time are associated with individual gastroenterologists and anesthesiologists, their years of experience, and the presence of supervised participants.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Comparison of the effects of esketamine, sufentanil, or lidocaine combined with propofol on tussis reflection during upper gastrointestinal endoscopy: study protocol for a randomised, two centre, three-blind, controlled trial

BACKGROUND

Tussis, which increases the incidence of airway spasm, aspiration, nausea, and vomiting, is a common complication faced during upper gastrointestinal (GI) endoscopy. However, sedatives and analgesics exhibit inhibitory actions against airway reflexes to different degrees. Our assumption is a combination of propofol and small doses of sufentanil, esketamine, or lidocaine, especially the combination of propofol and esketamine, might reduce tussis incidence.

METHOD

The study will be performed as a randomised controlled three-blind, two-centre trial. Patients undergoing upper GI endoscopy, ≥ 18 years old, with American Society of Anesthesiologists (ASA) classification I-III will be randomised to four groups: P group (single administration of propofol), P + S group (administration of propofol and sufentanil in combination), P + K group (administration of propofol and esketamine in combination), and P + L group (administration of propofol and lidocaine in combination) (N = 100 per group). The primary endpoints include the frequency of tussis, nausea and vomiting, and/or body movements observed at the insertion of the endoscope into the pharyngeal cavity or within 5 min of endoscope insertion. Secondary outcomes are recovery assessment, patients' and endoscopists' satisfaction with the procedure, MMSE scores, MET scores, sleep condition, and the number of sedation-related events. Data on sedation-related events are collected by recording of vital signs. Satisfaction parameters and mental states are collected by means of questionnaires and evaluation scales before and after the procedure and on different following days.

DISCUSSION

Esketamine can reduce tussis occurrence with good tolerability and relax the bronchus and also provides high clearance rates and low possibility of adverse reactions. We aim to demonstrate that the combination of esketamine with propofol for sedation in patients subjected to upper GI procedure is nevertheless superior to only administration of propofol or a combination of propofol with other anaesthetics, such as opioids or lidocaine.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT05497492 , Registered 09 August 2022.

Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature

Although efficacy and safety of nonanesthesiologist administration of propofol and nurse-administered propofol sedation practices have been amply demonstrated in patients at low American Society of Anesthesiologists physical status risk, they are still severely limited. To date, it is quite difficult to find a protocol or a shared training program. The aim of the study was to verify requirements, types of training, and operating methods described in the literature for the administration of propofol by a nurse. A scoping review of the literature was conducted in accordance with the PRISMA-ScR guidelines and in line with Arksey and O'Malley's framework, within four main databases of biomedical interest: MEDLINE, CINAHL, Scopus, and Web of Science. We selected studies published during the last 20 years, including only nurses not trained in anesthesia. Seventeen articles were eligible. Despite the differences between the training and administration methods, efficacy and safety of deep sedation managed by trained nurses were comparable, just like when sedation was administered by certified registered nurse anesthetists. Training programs have been investigated in detail by only a small number of studies, although its efficacy and safety have been widely demonstrated. It is important, then, to collect evidence that allows developing of unified international guidelines for training methods to offer safe and cost-effective quality sedation.

Enhancing the Quality of Upper Gastrointestinal Endoscopy: Current Indicators and Future Trends

The quality of upper gastrointestinal endoscopy (EGD) is crucial and carries significant consequences for patient outcomes, the employment of healthcare resources, and the future course of gastroenterology as a medical specialty. In this review, we navigate through the terrain of the Quality Indicators (QIs) for EGD, shedding light on their indispensable function in ensuring and augmenting the quality of patient care throughout the pre-procedural, intra-procedural, post-procedural, and outcome-oriented facets of the practice. We delve into the comprehensive scope of the QIs and the challenges impeding the delivery of high-quality EGD, from variability in practitioner training and patient compliance to the systemic limitations of current QIs and the barriers hindering the adoption of advanced techniques. Future directions for bolstering the quality of EGD are highlighted, encapsulating the integration of emergent endoscopic technologies, the evolution of patient-centered metrics, the refinement of endoscopist training and credentialing processes, and the promise held by Artificial Intelligence (AI). Particular emphasis is placed on the role of advanced endoscopic techniques and equipment in enhancing EGD quality. This article presents a cogent narrative, promoting the pursuit of excellence in EGD as an ever-evolving endeavor that necessitates the collective dedication of clinicians, researchers, educators, and policymakers.

Operational outcomes of propofol sedation versus fentanyl, midazolam and diphenhydramine sedation for endoscopies and colonoscopies at an academic medical center

BACKGROUND

On July 1st, 2021, the University of Colorado Hospital (UCH) implemented new sedation protocols in the luminal gastrointestinal (GI) suite. GI proceduralist supervised, Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS) sedation was transitioned to Monitored Anesthesia Care with propofol under physician anesthesiologist supervision (MAC).

OBJECTIVE

To determine if there are statistically significant reductions in Sedation-Start to Scope-In time (SSSI) when using Monitored Anesthesia Care with propofol (MAC) versus Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS). Secondary objectives were to determine if statistically significant improvements to other operational times, quality measures, and satisfaction metrics were present.

METHOD

This study was a retrospective analysis of a natural experiment resultant of a change from NAS to MAC sedation protocols. Outcomes for NAS protocols from 1/1/21-6/30/21 were compared to outcomes of MAC protocols from the dates 8/1/21-10/31/21. Results were analyzed using Quasi-Poisson regression analysis and stratified based on upper GI, lower GI, and combined procedures. Patient demographic data including age, biological sex, comorbidities, and BMI, were adjusted for in the analysis. ASA matching was not performed as nursing sedation does not use ASA classifications. Pre-anesthesia co-morbidities were assessed via evaluation of a strict set of comorbidities abstracted from the electronic medical record. Perioperative operational outcomes include Sedation Start to Scope-In (SSSI), In-Room to Scope-In Time (IRSI), Scope Out to Out of Room (SOOR), Total Case Length (TCL), and Post Anesthesia Care Unit Length of Stay (PACU LOS). Quality outcomes include PACU Administered Medications (PAM), and Clinician Satisfaction Scores (CSS).

RESULTS

A total of 5,582 gastrointestinal (GI) endoscopic cases (upper, lower, and combined endoscopies) were observed. Statistically significant decreases in SSSI of 2.5, 2.1, and 2.2 minutes for upper, lower, and dual GI procedures were observed when using MAC protocols. A statistically significant increase in satisfaction scores of 47.0 and 19.6 points were observed for nurses and proceduralists, respectively, when using MAC.

CONCLUSION

MAC protocols for endoscopic GI procedures at UCH led to statistically significant decreases in the time required to complete procedures thus increasing operational efficiency.

The safety and efficacy between remimazolam and propofol in intravenous anesthesia of endoscopy operation: a systematic review and meta-analysis

BACKGROUND

Propofol is the most widely used intravenous anesthetic in endoscopic surgery, but is associated with several adverse reactions. Public research has shown that remimazolam, a safe general anesthetic, is increasingly being used as a substitute for propofol in clinical operations. Our meta-analysis aimed to analyze whether the adverse reaction rate of remimazolam in endoscopic surgery is acceptable and whether the surgical success rate is not lower than that of propofol.

AIM

This meta-analysis examined the adverse events and efficacy of remimazolam vs. propofol during endoscopic surgery.

METHOD

MEDLINE, Embase, ClinicalTrials.gov, and Google Scholar were comprehensively searched. Seven studies comparing remimazolam and propofol were included in our meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane manual were used to assess the quality of the results published in all included studies to ensure that our meta-analysis results are reliable and worthwhile.

RESULTS

Compared to propofol, the use of remimazolam reduced postoperative injection pain [relative risk (RR)=0.06, 95% confidence interval (CI): 0.03-0.12, P <0.00001], postoperative hypotension (RR=0.45, 95% CI: 0.28-0.73, P =0.001), and postoperative respiratory depression (RR=0.20, 95% CI: 0.08-0.47, P =0.0002); however, it also slightly reduced the success rate of the operation [risk difference (RD)=-0.02, 95% CI: -0.04 to -0.01, P =0.0007]. There were no significant differences in the occurrence of bradycardia symptoms after the operation (RD=-0.01, 95% CI: -0.03 to 0.01, P =0.35), recovery time after the operation [standardized mean difference (SMD)=0.68, 95% CI: -0.43 to 1.80, P =0.23] or discharge time (SMD=0.17, 95% CI: -0.58 to 0.23, P =0.41). We also performed a subgroup analysis of each corresponding outcome.

CONCLUSION

Our analysis showed that remimazolam may be a safer shock option than propofol for endoscopic surgery. However, further research is required to determine their utility.

Efficacy and Safety of Different Doses of Remimazolam Tosilate Applied in Upper Gastrointestinal Endoscopy: A Prospective Randomized Controlled Double-Blind Trial

Background

Remimazolam is a novel benzodiazepine narcotic. When used for gastrointestinal endoscopy or bronchoscopy, it provides adequate sedation and rapid recovery. However, studies on the optimal initial loading dose of remimazolam remain inadequate. Therefore, we conducted a randomized controlled clinical trial to investigate the efficacy and safety of different doses of remimazolam applied in upper gastrointestinal endoscopy.

Methods

A total of 218 patients scheduled for upper gastrointestinal endoscopy were included in our trial and divided into experimental and control groups: the experimental groups were the remimazolam groups (R1 of 0.2 mg/kg, R2 of 0.3 mg/kg, and R3 of 0.4 mg/kg), and the control group was the propofol group. Following a single injection of trial drugs during the induction period, operational requirements were evaluated based on MOAA/S scores. When the sedation was successfully achieved, safety was evaluated based on the incidence of various intraoperative and postoperative adverse events.

Results

The success rates of intraoperative sedation were 82% in group R1, 98% in group R2, 96% in group R3, and 100% in group P. The incidence of hypotension was lower in the remimazolam groups than in the propofol group (16%), 4% in group R1, 6% in group R2, and 6% in group R3. The incidence of postoperative vertigo was significantly higher, and sedation recovery time was prolonged in high-concentration remimazolam group.

Conclusion

Satisfactory efficacy can be obtained with higher concentrations of remimazolam tosilate in patients undergoing upper gastrointestinal endoscopy with ASA grade I or II. However, as the dose is progressively increased, the incidence of adverse reactions by remimazolam tosilate are also significantly increased, such as vertigo and prolonged sedation recovery time.

Trial Registration

The trial was registered prior to enrollment at the Chinese Clinical Trial Registry (ChiCTR 2000032067).

Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study

Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.

The efficacy of non-anesthesiologist-administered propofol sedation with a target-controlled infusion system during double-balloon endoscopic retrograde cholangiopancreatography

BACKGROUND

The sedation method used during double-balloon endoscopic retrograde cholangiopancreatography (DB-ERCP) differs among countries and/or facilities, and there is no established method. This study aimed to evaluate the efficacy of non-anesthesiologist-administered propofol (NAAP) sedation using a target-controlled infusion (TCI) system during DB-ERCP.

METHODS

This retrospective study was conducted between May 2017 and December 2020 at an academic center. One hundred and fifty-six consecutive patients who underwent DB-ERCP were sedated by gastroenterologists using diazepam (n = 77) or propofol with a TCI system (n = 79), depending on the period. The primary endpoint was a comparison of poor sedation rates between the two groups. Poor sedation was defined as a condition requiring the use of other sedative agents or discontinuation of the procedure. Secondary endpoints were sedation-related adverse events and risk factors for poor sedation.

RESULTS

Poor sedation occurred significantly more often in the diazepam sedation group (diazepam sedation, n = 12 [16%] vs. propofol sedation, n = 1 [1%]; P = 0.001). Vigorous body movements (3 or 4) (diazepam sedation, n = 40 [52%] vs. propofol sedation, n = 28 [35%]; P = 0.038) and hypoxemia (< 85%) (diazepam sedation, n = 7 [9%] vs. propofol sedation, n = 1 [1%]; P = 0.027) occurred significantly more often in the diazepam sedation group. In the multivariate analysis, age < 70 years old (OR, 10.26; 95% CI, 1.57-66.98; P = 0.015), BMI ≥ 25 kg/m2 (OR, 11.96; 95% CI, 1.67-85.69; P = 0.014), and propofol sedation (OR, 0.06; 95% CI, 0.01-0.58; P = 0.015) were associated factors for poor sedation.

CONCLUSIONS

NAAP sedation with the TCI system during DB-ERCP was safer and more effective than diazepam sedation.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Factors influencing the reliability of intraoperative testing in deep brain stimulation for Parkinson's disease

BACKGROUND

Several meta-analyses comparing the outcome of awake versus asleep deep brain stimulation procedures could not reveal significant differences concerning the postoperative improvement of motor symptoms. Only rarely information on the procedural details is provided for awake operations and how often somnolence and disorientation occurred, which might hamper the reliability of intraoperative clinical testing. The aim of our study was to investigate possible influencing factors on the occurrence of somnolence and disorientation in awake DBS procedures.

METHODS

We retrospectively analyzed 122 patients with Parkinson's disease having received implantation of a DBS system at our centre. Correlation analyses were performed for the duration of disease prior to surgery, number of microelectrode trajectories, AC-PC-coordinates of the planned target, UPDRS-scores, intraoperative application of sedative drugs, duration of the surgical procedure, perioperative application of apomorphine, and the preoperative L-DOPA equivalence dosage with the occurrence of intraoperative somnolence and disorientation.

RESULTS

Patients with intraoperative somnolence were significantly older (p=0.039). Increased duration of the DBS procedure (p=0.020), delayed start of the surgery (p=0.049), higher number of MER trajectories (p=0.041), and the patients' % UPDRS improvement (p=0.046) also correlated with the incidence of intraoperative somnolence. We identified the main contributing factor to intraoperative somnolence as the use of sedative drugs applied during skin incision and burr hole trepanation (p=0.019). Perioperatively applied apomorphine could reduce the occurrence of somnolent phases during the operation (p=0.026).

CONCLUSION

Several influencing factors were found to seemingly increase the risk of intraoperative somnolence and disorientation, while the use of sedative drugs seems to be the main contributing factor. We argue that awake DBS procedures should omit the use of sedatives for best clinical outcome. When reporting on awake DBS surgery these factors should be considered and adjusted for, to permit reliable interpretation and comparison of DBS study results.

Safety and feasibility of oesophageal ultrasound for the work-up of thoracic malignancy in patients with respiratory impairment

Biopsying lung tumours with endobronchial access in patients with respiratory impairment is challenging. However, fine needle aspiration with the endobronchial ultrasound-endoscope via the oesophagus (EUS-B-FNA) makes it possible to obtain tissue samples without entering the airways. Safety of EUS-B-FNA in these patients has not earlier been investigated prospectively. Therefore, this study aimed at assessing feasibility and safety of EUS-B-FNA from centrally located tumours suspected of thoracic malignancy in patients with respiratory insufficiency. The study is a prospective observational study. Patients with indication of EUS-B-FNA of centrally located tumours and respiratory impairment defined as modified Medical Research Council (mMRC) dyspnoea scale score of ≥3, saturation ≤90% or need of continuous oxygen supply were included prospectively in three centres. Any adverse events (AEs) were recorded during procedure and 1-hour recovery. AEs were defined as hypoxemia (saturation <90% or need for increased oxygen supply) or any kind of events needing intervention. Late procedure-related events were recorded during 30-day follow-up. Between April 1, 2020 and January 30, 2021, 16 patients were included. No severe AEs (SAEs) occurred, but AEs were seen in 50% (n=8) and 13% (n=2) of the patients during procedure and recovery respectively. AEs included hypoxemia corrected with increased oxygen supply and in two cases reversal of sedation. Late procedure-related events were seen in 13% (n=2) and included prolonged need of oxygen and one infection treated with oral antibiotics. In this cohort, EUS-B-FNA of centrally located tumours was safe and feasible in patients with respiratory impairment, when examined in the bronchoscopy suite. A variety of mostly mild and manageable complications may occur, a few even up to 30 days post-procedure.

Safety and effectiveness of the combination of remimazolam tosilate and propofol in gastroscopy: a multicenter, randomized controlled, single-blind clinical trial

Remimazolam tosilate (RT) is a new short-acting γ-aminobutyric acid A (GABAA) receptors agonist. However, its optimal use mode and dosage still remain unclear. This study aimed to examine the safety and effectiveness of the combination of RT and propofol in gastroscopy. This was a prospective, single-blind, randomized, multicenter, parallel-group study. All eligible 256 patients were randomized into the following 3 groups. Patients were anesthetized with propofol (Group P), RT (Group R) or the combination of RT and propofol (Group RP). The primary efficacy endpoints were: body movement score; satisfaction of gastroscopy doctors; success rate of sedation and effects on sleep status. Sedation induction time, time to be fully alert and adverse events were also recorded. The probability of complete immobility was lower in group R (33.73%) than in group P (86.67%) and RP (83.13%). The rate of doctors' satisfaction was much lower in group R (28.92%) than in group P (77.78%) and RP (72.29%). The success rate of sedation and sleep outcome score has no difference in the three groups. The time to adequate sedation was longer in group RP (77.27 ± 18.63 s) than in group P (64.47 ± 24.36 s), but much shorter than that in group R (102.84 ± 46.43s). The time to be fully alert was shorter in group R (6.30 ± 1.52 min) and RP (6.54 ± 1.13 min) than in group P (7.87 ± 1.08 min). The proportion of sedative hypotension was significantly higher in group P (41.11%) than in group R (1.20%) and group RP (3.61%) (p < 0.001). The incidence of respiratory depression was much higher in group P (17.78%) than in group R (no patient) and group RP (1.2%). The incidence of adverse events was lower in groups R (4.82%) and RP (9.64%) than in group P (31.11%). The combination of RT and propofol takes effect quickly, makes patients alert quickly, provides a sufficient depth of sedation, reduces body movement, does not inhibit circulation and respiratory function, does not affect sleep, and is the preferred mode for gastroscopy doctors and anesthesiologists.

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies

BACKGROUND

Sedation is common practice in endoscopic procedures to suppress a patient's level of consciousness while maintaining the cardio-respiratory function. Midazolam and propofol are the sedatives most frequently used for procedural sedation at the hospitals in Scandinavia. Remimazolam is a new ultra-short-acting benzodiazepine sedative and the present analysis aimed at estimating the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia.

METHOD

We developed a cost model applying a micro-costing approach that comprised the cost components that are affected by differences in the efficacy of remimazolam, midazolam and propofol, and the model estimated the cost per successful colonoscopy and bronchoscopy when using remimazolam, midazolam or propofol as sedation. A micro-costing approach was applied, and the model consisted of six stages representing the journey for patients undergoing endoscopies and was informed primarily by data from clinical studies on remimazolam.

RESULTS

We found a total cost of DKK 1,200 per successful colonoscopy procedure when using remimazolam, a total cost of DKK 1,320 when using midazolam and a total cost of DKK 1,255 when using propofol. Hence, the incremental saving per successful colonoscopy procedure of using remimazolam was estimated to be DKK 120 compared to midazolam and DKK 55 compared to propofol. The total cost per successful bronchoscopy procedure when using remimazolam was DKK 1,353 and DKK 1,724 for midazolam, resulting in an incremental saving per bronchoscopy of DKK 372 when using remimazolam. Performed sensitivity analyses identified the time in recovery as the largest contributor to uncertainty in the analyses of remimazolam compared to midazolam in colonoscopies and bronchoscopies. In the comparison of remimazolam and propofol in colonoscopies, procedure time was the largest contributor to uncertainty.

CONCLUSION

We found that procedural sedation with remimazolam was associated with economically meaningful savings compared to procedural sedation with midazolam and propofol in colonoscopies and to midazolam in bronchoscopies.

Effect of electroacupuncture on discomfort during gastroscopy: A randomised controlled trial

BACKGROUND

Gastrointestinal reactions, pain and discomfort are inevitable in patients undergoing common gastroscopy. Acupuncture is an effective therapy that assists in the perioperative period; however, evidence of it relieving discomfort is limited. We conducted this trial to observe the effect of electroacupuncture (EA) on discomfort caused by gastroscopy without sedatives.

METHODS

This was a single-centre, patient-assessor blind, randomised controlled trial. Sixty patients requiring gastroscopy were randomly assigned to the EA and control groups (sham acupuncture, SA, group) in a 1:1 ratio. Patients in the EA group underwent treatment at acupoints LI4 (Hegu), PC6 (Neiguan), ST36 (Zusanli), and ST34 (Liangqiu) for 30 min before gastroscopy, whereas patients in the SA group underwent superficial acupuncture at non-acupoints. The patients' nausea level, throat discomfort, bucking, and agitation were evaluated using a visual analogue scale (VAS) within 30 min after gastroscopy. The mean VAS score was the primary outcome. Secondary outcomes were the Amsterdam Preoperative Anxiety and Information Inventory Scale, used to evaluate patients' preoperative anxiety levels, and the 6-item State-Trait Anxiety Inventory (STAI-S6), used to assess anxiety before and after gastroscopy. The patients' vital signs, including heart rate, blood pressure, and pulse oxygen saturation, were recorded before, during, and after gastroscopy.

RESULTS

At 30 min after gastroscopy, the mean VAS score in the EA group (4.20 ± 0.63) was lower than that in the control group (5.14 ± 0.70, mean difference (MD): - 0.94, 95% confidence interval (CI): - 1.28, - 0.59, P < 0.001). There were statistically significant between-group differences in the nausea and vomiting, throat discomfort and agitation VAS scores (all P < 0.01), whereas no difference was found in the bucking VAS score (P = 0.692). Compared with the SA group, patients in the EA group had a 6.90-point lower in STAI-S6 (95% CI: -12.98, -0.81, P = 0.027) after gastroscopy. Patients in the EA group had a slower heart rate and lower blood pressure than those in the SA group. Serious adverse events were not observed during the trial.

CONCLUSION

EA can help relieve patients' anxiety, and improve their nausea and vomiting, throat discomfort, and agitation during gastroscopy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ID: ChiCTR2000040726.

Application of topical pharyngeal anesthesia to reduce adverse reactions during painless gastroscopy: A prospective randomized study

BACKGROUND

Studies have reported that certain adverse reactions can occur during painless gastroscopy examination. Knowing how to decrease the risks and incidence of adverse reactions is of great importance.

OBJECTIVE

To investigate whether topical pharyngeal anesthesia combined with intravenous anesthesia is superior to intravenous anesthesia alone in patients undergoing painless gastroscopy and to determine whether this combined approach had any additional benefits.

METHODS

Three hundred patients undergoing painless gastroscopy were randomly assigned to either the control group or the experimental group. In the control group, patients were anesthetized with propofol, while patients in the experimental group received propofol combined with 2% lidocaine spray for topical pharyngeal anesthesia. Hemodynamic parameters before and after the procedure, including the heart rate (HR), mean arterial pressure (MAP), and pulse oxygen saturation (SPO2) were recorded. Any adverse reactions experienced by the patient, including choking and respiratory depression, and the total dosage of propofol required during each procedure were also documented.

RESULTS

Compared with pre-anesthetic data, the HR, MAP, and SPO2 were reduced after the completion of the painless gastroscopy procedure in both groups. However, the HR, MAP, and SPO2 measurements taken after the gastroscopy were significantly lower in the control group than those of the experimental group (P< 0.05); thus, the hemodynamic parameters of the experimental group were more stable. Compared with the control group, there was significant reduction in the total amount of propofol administered in the experimental group (P< 0.05). The incidence of adverse reactions, including choking and respiratory depression, was significantly lower in the experimental group (P< 0.05).

CONCLUSION

The results demonstrated that the application of topical pharyngeal anesthesia in painless gastroscopy can significantly reduce the incidence of adverse reactions. Thus, the combination of topical pharyngeal and intravenous anesthesia is worthy of clinical application and promotion.

Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care

PURPOSE

Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC.

MATERIALS AND METHODS

We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC).

RESULTS

We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l₁ regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively.

CONCLUSION

We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.

Time and Motion at the Endoscopy Unit-A University Hospital Experience

Background/aims

An effective workflow at the endoscopy unit is important for optimal production. We conducted a time-and-motion study to identify the amount of time that patients spend during the different steps of a regular endoscopy procedure and compared propofol with midazolam sedation.

Methods

Data from 376 patients were prospectively collected. Durations of the different procedure steps were measured. Correlations between recovery times, age, and dose of sedative were calculated. Multiple regression analysis was performed to evaluate how various factors affect recovery time.

Results

The use of midazolam resulted in significantly shorter procedure duration for gastroscopy (5.1 vs 8.3 min), shorter endoscopist delay duration for either types of endoscopy (5.9 vs 8.3 min for gastroscopy and 6.7 vs 11.4 min for colonoscopy), shorter endoscopy room duration for gastroscopy (22.2 vs 30.0 min), shorter recovery time for colonoscopy (23.4 vs 27.4 min) and shorter Endoscopy Unit Duration for either type of endoscopy (77.1 vs 101.4 min for gastroscopy and 99.6 vs 123.2 min for colonoscopy). There was a weak correlation between dose of midazolam and recovery time.

Conclusions

In contrast to other studies, propofol administration leads to more time spent at different steps in the workflow at our unit. Implementing propofol sedation will not improve efficacy if other steps in the workflow are not taken into account.

Comparison of effectiveness, cost and safety between moderate sedation and deep sedation under esophagogastroduodenoscopy in Chinese population: a quasi-experimental study

OBJECTIVE

Most endoscopists routinely perform moderate or deep sedation for esophagogastroduodenoscopy (EGD). Considering that there is no consensus on the optimal sedation depth and it varies from country to country, our study aims to compare the effectiveness, cost and safety of these two sedation methods in the Chinese population.

METHODS

This quasi-experimental study included a total of 556 eligible patients from July 2020 to June 2021, and they entered the moderate sedation group or deep sedation group based on their choices. Baseline information, scores of Patient Satisfaction with Sedation Instrument (PSSI) and Clinician Satisfaction with Sedation Instrument (CSSI), examination time, sedation time, recovery time, expenses before medicare reimbursement, hypoxaemia and hypotension were compared between the two groups. Propensity Score Matching (PSM) analysis was conducted to balance the confounding factors.

RESULTS

After PSM, 470 patients were involved in the analysis, with 235 for each group. The moderate sedation was clearly superior to the deep sedation group in terms of PSSI score (98.00 ± 0.94 vs. 97.29 ± 1.26), CSSI score (98.00 ± 0.78 vs. 97.67 ± 1.30), sedation time (11.90 ± 2.04 min vs. 13.21 ± 2.75 min), recovery time (25.40 ± 3.77 min vs. 28.0 ± 4.85 min), expenses (433.04 ± 0.00 Yuan vs. 789.85 ± 0.21 Yuan), with all p < .001. Examination time was not significantly different between the two groups (p = .124). In addition, the moderate sedation group had a lower occurrence rate of hypoxaemia (0.36% vs. 3.27%, p = .010) and hypotension (17.44% vs. 44.00%, p < .001) compared to the deep sedation group.

CONCLUSIONS

Moderate sedation presented better effectiveness and safety and lower cost, and thereby it should be recommended as a widely used sedation method in clinical practice in China. Trial registration: This trial was registered on http://www.chictr.org.cn/index.aspx (ChiCTR2000038050).

Modified Lamaze Breathing Reduces Abdominal Pain in Patients during Colonoscopy

Objective. To study the effects of modified Lamaze breathing on abdominal pain experienced during colonoscopy. Methods. Eighty-five patients who underwent common colonoscopy at our hospital between March 2021 and May 2021 were selected and randomly divided into the Lamaze group ( $n=40$ ) and a control group ( $n=45$ ). Their basic clinical information was collected, and the bowel cleanliness, the time for the endoscope to reach the ileocecal junction, and the degree of abdominal pain of the two groups were compared. Results. No significant difference was observed in age, gender, bowel cleanliness, and time of endoscope to reach the ileocecal junction between the two groups. However, the degree of abdominal pain (anal region, descending sigmoid colon junction, splenic flexure, and hepatic flexure) was significantly lower in the Lamaze group compared with the control group. Conclusion. Modified Lamaze breathing demonstrated promising effectiveness in reducing abdominal pain during colonoscopy and improving the quality of the examination.

Gastrointestinal and non-gastrointestinal complication rates associated with diagnostic esophagogastroduodenoscopy under sedation

Esophagogastroduodenoscopy (EGD) under sedation may result in gastrointestinal (GI) and non-GI complications. However, no previous studies have reported 30-day GI and non-GI complications after diagnostic EGD under sedation.We conducted a retrospective, observational study of 30-day GI and non-GI complication rates after outpatient diagnostic EGD under sedation in subjects ≥18 years between January 2012 and December 2017 based on a common data model database. Thirty-day complication rates were compared with EGD under sedation or not, type of sedation drugs (midazolam only vs midazolam/propofol) and age groups (18-64 year vs ≥65 year) for GI (bleeding and perforation) and non-GI complications (pneumonia, acute myocardial infarction, congestive heart failure and cerebral stroke).In total, 39,910 were performed with sedation (midazolam only, n = 16,033 and midazolam/propofol, n = 23,864) and 22,894 were performed without sedation. Elderly patients significantly favored EGD without sedation (P < .01). GI and non-GI complication rates were similar between EGD under sedation and without sedation (all P > .1) except for acute myocardial infarction rate, which was significantly higher in EGD without sedation than EGD under sedation (1.7/10,000 vs 0.3/10,000 persons, P = .043). All GI and non-GI complications were also similar between the midazolam/propofol and midazolam only groups as well as between young and old patients (all P > .1).Outpatient diagnostic EGD under sedation has an excellent safety profile. In addition, it can be safely performed with midazolam only or midazolam/propofol and in young and old patients.

Implementation of virtual reality technology to decrease patients' pain and nervousness during colonoscopies: a prospective randomised controlled single-blinded trial

BACKGROUND

Improved patient satisfaction in endoscopy is worthy of study as it is an invasive and potentially uncomfortable procedure. There is growing literature on patient satisfaction assessment in endoscopy as part of improving quality assurance. This study aimed to determine whether virtual reality (VR) technology can decrease patients' pain and nervousness during colonoscopies.

METHODS

Patients enrolled without sedation were randomly categorised into groups that watched VR (VR group; n=58) and those that did not watch VR (control group; n=59). The primary outcomes were pain score and skin conductance. Secondary endpoints included heart rate, systolic and diastolic arterial pressures, overall patient satisfaction, willingness to repeat the procedure, the difficulty of the procedure, the procedure duration, and bowel preparation.

RESULTS

The median (interquartile range (IQR)) pain scores were 7 (6-8) and 5 (4-6) in the control and VR groups, respectively (p<0.001). The median (IQR) skin conductance values after colonoscope insertion were 0.660 (0.490-0.840) and 0.390 (0.280-0.600) in the control and VR groups, respectively (p<0.001). Overall, patient satisfaction was significantly improved with the use of VR, along with a significant reduction in the difficulty perceived by the endoscopist.

CONCLUSION

VR technology helped to reduce patients' pain and nervousness and to improve patients' satisfaction during colonoscopies.

Virtual reality distraction during upper gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND AND AIM

Virtual reality (VR) is an established and effective tool in reducing autonomic and somatic pain. We aimed to examine the analgesic effects of VR distraction during esophagogastroduodenoscopy (EGD).

METHODS

We conducted a randomized controlled trial and enrolled patients who had indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensional specific software content (standalone VR headset), sham VR or without VR during EGD. The primary outcome was patient pain scores during EGD.

RESULTS

A total of 96 patients undergoing diagnostic EGD were randomized to receive VR (n = 32), sham VR (n = 32), and no VR defined as the control group (n = 32). Patients in all groups reported no statistically different pain during esophageal intubation. The mean pain score was 2.7 ± 2.4 in the VR group, 2.7 ± 2.5 in the sham VR and 2.3 ± 2.3 in the control group, (P value = 0.751). No significant difference was observed in heart rate and blood pressure, and the endoscopists reported higher overall satisfaction scores in VR (4.3 ± 0.5) compared with the control group (4 ± 0.8) but without significance (P value = 0.156).

CONCLUSION

Virtual reality-assisted anesthesia during EGD did not significantly reduce patient pain during esophageal intubation. There was no superiority in using VR distraction regarding patient's and endoscopist's satisfaction compared with standard EGD without VR Further studies are required to detect any true clinical advantage of VR distraction during EGD.

Validity Analysis of Neck Circumference as a Screening Test for Hypoxia Occurrence in Patients Undergoing Sedative Endoscopy

This study was performed to check the validity of and propose a cutoff point for measuring the neck circumference for screening hypoxia occurrence in patients undergoing sedative endoscopy. Data were collected from 168 patients who visited the Endoscopy Center of G University Hospital between 27 April 2020 and 12 June 2020 to undergo sedative endoscopy. Hypoxia occurrences were measured using sleep questionnaires (STOP-BANG and Berlin questionnaires), and the neck circumference measurements of the patients were compared. Neck circumference as a predictor of hypoxia and its sensitivity and specificity according to the cutoff values were high; thus, it is a valid screening test for hypoxia in patients undergoing sedative endoscopy. The most appropriate cutoff values for sitting neck circumference and lying neck circumference in men were 40.5 and 40.3, respectively, and those for women were 35.3 and 35.8, respectively. Hypoxia can be predicted in patients undergoing sedative endoscopy by measuring their neck circumference.

Effect of remimazolam tosilate on early cognitive function in elderly patients undergoing upper gastrointestinal endoscopy

BACKGROUND AND AIM

Remimazolam tosilate (RT) is under evaluation as a sedative for endoscopic procedures. Herein, we aimed to evaluate safety including cognition recovery of RT administered in elderly patients undergoing upper gastrointestinal endoscopy and assess its safety dosage.

METHODS

Ninety-nine patients presenting for upper gastrointestinal endoscopy were randomized to receive 0.1 mg/kg RT (R1) or 0.2 mg/kg RT (R2), or propofol (P). Cognitive functions (memory, attention, and executive function) were measured via neuropsychological tests conducted before sedation and 5 min after recovery to full alertness. Adverse events were also assessed.

RESULTS

There were no statistical differences between postoperative and baseline results for R1 group and P group, whereas those for R2 group revealed worsened postoperative cognitive functions (immediate recall and short delay recall) than baseline (P < 0.05). Compared with P group, Scores demonstrated worse restoration of immediate recall in R1 group, immediate recall, short-delayed recall, and attention function in R2 group (P < 0.05). Patients in R2 group had a longer sedation time (12.09 vs 8.27 vs 8.21 min; P < 0.001) and recovery time (6.85 vs 3.82 vs 4.33 min; P < 0.001) than that in R1 group and P group. Moreover, the incidence of hypotension was 3.0% in R1 group, whereas it was 21.2% in R2 group and 48.5% in P group (P < 0.05).

CONCLUSION

The addition of 0.1 mg/kg RT as an adjunct to opiate sedation for upper gastrointestinal endoscopy not only achieves more stable perioperative hemodynamics but also achieves acceptable neuropsychiatric functions in elderly patients.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement.

METHODS

6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables.

RESULTS

In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy.

CONCLUSIONS

On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy

Diagnostic unsedated transnasal endoscopy (uTNE) has been proven to be a safe and well-tolerated procedure. Although its utilization in the United Kingdom (UK) is increasing, it is currently available in only a few centers. Through consideration of recent studies, we aimed to perform an updated review of the technological advances in uTNE, consider their impact on diagnostic accuracy, and to determine the role of uTNE in the COVID-19 era. Current literature has shown that the diagnostic accuracy of uTNE for identification of esophageal pathology is equivalent to conventional esophagogastroduodenoscopy (cEGD). Concerns regarding suction and biopsy size have been addressed by the introduction of TNE scopes with working channels of 2.4 mm. Advances in imaging have improved detection of early gastric cancers. The procedure is associated with less cardiac stress and reduced aerosol production; when combined with no need for sedation and improved rates of patient turnover, uTNE is an efficient and safe alternative to cEGD in the COVID-19 era. We conclude that advances in technology have improved the diagnostic accuracy of uTNE to the point where it could be considered the first line diagnostic endoscopic investigation in the majority of patients. It could also play a central role in the recovery of diagnostic endoscopic services during the COVID-19 pandemic.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.