Unsedated transnasal versus transoral sedated upper gastrointestinal endoscopy: a one-series prospective study on safety and patient acceptability

BACKGROUND

While conventional oesophagogastroduodenoscopy is frequently performed under sedation to improve acceptability, transnasal oesophagogastroduodenoscopy would appear to be less invasive.

STUDY AIMS

To compare diagnostic accuracy, feasibility, acceptability and safety of transnasal oesophagogastroduodenoscopy without sedation versus conventional oesophagogastroduodenoscopy under sedation.

PATIENTS

Following anxiety assessment, 30 dyspeptic patients underwent transnasal oesophagogastroduodenoscopy under local anaesthesia (lidocaine) and conventional oesophagogastroduodenoscopy under conscious sedation (i.v. midazolam) on two consecutive days. Transnasal oesophagogastroduodenoscopy was performed with an ultrathin and conventional oesophagogastroduodenoscopy with a standard endoscope.

METHODS

Safety, evaluated by monitoring cardio-respiratory functions. Acceptability, rated according to discomfort and preference between the two examinations. Diagnostic accuracy evaluated taking into account endoscopic patterns and adequacy of biopsy specimens for histology. Feasibility, defined according to endoscopic performance, quality of images and overall opinion of the endoscopist. Only gastric biopsies were evaluated.

RESULTS

All patients but one who refused conventional oesophagogastroduodenoscopy underwent both transnasal oesophagogastroduodenoscopy and conventional oesophagogastroduodenoscopy. No cardiorespiratory complications occurred during either technique. Majority of patients (87%) preferred transnasal oesophagogastroduodenoscopy. Examinations were completed in all cases, with comparable endoscopic patterns. All biopsy specimens were suitable for histology.

CONCLUSIONS

Transnasal oesophagogastroduodenoscopy without sedation provides good diagnostic accuracy, is safer and better accepted than conventional oesophagogastroduodenoscopy under sedation and, therefore, represents a valid alternative in routine diagnosis of upper digestive tract diseases.

Relevance of information in informed consent to digestive endoscopy

In the field of instrumental methodologies, digestive endoscopy is widely applied diagnostic and therapeutic investigation, involving ethical and medico-legal problems connected with its performance. So, in the light of the present doctor-patient relationship, we therefore wished to reconsider the relevant meaning of preventive information which is indispensable for obtaining the patient's consent to the doctor's action. The aim of this present paper is to provide adequate knowledge, for who ever is about to undergo endoscopic examination, by introducing new informative forms and a new system for their distribution, without negatively affecting the patient's state of anxiety. We have tried to attribute greater responsibility to the person of the doctor requesting the examination, in providing information for the patient, and to underline, in the case of complications, the important conduct of the endoscopic specialist, who must not fail to obtain new informed consent before submitting the patient to any action directed towards treatment of the specific complication. If ignored, these medico-legal aspects can formulate the responsibility of the doctor both in clinical or penal context.

[Tissue expression of carbohydrate antigen 19-9 (CA 19-9) in adenomatous lesions of the colorectum]

Serum levels of tumor markers almost not detectable in precancerous states or early cancer, the behavior of the tumor associated antigen CA 19-9 in colorectal carcinogenesis was analysed. In order to investigate the adenoma-carcinoma sequence, tissue antigenic expression was measured in adenomas, characterized by different size and histology, and compared with that found in normal colonic mucosa. Tissue content of CA 19-9 was determined by an immunoperoxidase technique (ABC-POD) in 88 colonic polyps, and correlated to the degree of histological dysplasia, and dimension of adenoma. Tissue content of CA 19-9 was also evaluated in non-adenomatous mucosa obtained by endoscopic biopsy. Among the 88 polyps, 50 showed the tubular histological type, while 31 resulted tubulovillous and 7 villous. High degree of dysplasia was present in 7 adenomas (7.9%) and focal carcinoma was observed in 6 (6.8%). Positivity for CA 19-9 was registered in 60.2% of adenomas. No correlation was found between tissue-CA 19-9 and degree of dysplasia, size of adenoma and villous component. However, a statistically significant correlation was observed between expression and cellular distribution of the antigen (chi 2 = 98.07, p < 0.00001). Our data confirmed CA 19-9 expression in adenomas, but it is unlikely this tissue antigen proves to be a reliable marker of adenoma-carcinoma sequence.

Leiomyoma of the esophagus. (A case report)

Leiomyoma is the most common benign tumor of the esophagus. Its occurrence is fairly infrequent and in 50% of cases is asymptomatic. The case of esophageal leiomyoma (EL) which attracted our attention is of interest. The patient, a 44 years old women clinically assessed for cardiac rhythm disturbance with no compliant of dysphagia, had two locations of EL, demonstrated by x-ray, computed tomography and esophagoscopy. The treatment was performed in two phases, surgical and endoscopic, in relation to the non identification of the upper EL through the left thoracetomy. The various technical possibilities must all be evaluated in relation to every single case.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome): advances in management

The management of the patients with acute pseudo-obstruction of the colon (APOC) still represents a matter of debate. To better evaluate and compare the effectiveness of various therapeutic approaches in the management of APOC 29 patients were considered. These were included according to three consecutive periods in: group A (1977-1982) concerning patients who underwent medical treatment alone (n = 8) or endoscopic (n = 4) and surgical (n = 1) decompression; group B (1983-1990) in which the management was based on simple endoscopic decompression (n = 10); group C (1991-1995) including patients in whom placement, under fluoroscopic control, of a tube in the cecum following endoscopic decompression was provided (n = 6). Mean time required for resolution of colonic distension was 2.3 (+/- 0.50 SD) days in patients who underwent endoscopic decompression and tube placement, as compared to 4.5 (+/- 2.47 SD) days in the group of patients treated either with conservative measures or simple endoscopic decompression (p = 0.04). No recurrence occurred after colonoscopic decompression and tube placement while colonic distension recurred in 4 of 14 patients managed by simple endoscopic decompression (0% vs. 28.6%, n.s.). Our experience showed that endoscopic decompression is an effective method, moreover if associated with the placement of an indwelling tube into the right colon. This method, for its easiness and safeness, besides its effectiveness in preventing the recurrence of colonic distension, may be surely considered an advance in the management of acute pseudo-obstruction of the colon.

Major acute inflammatory complications of diverticular disease of the colon: planning of surgical management

BACKGROUND/AIMS

The aim of this study was to determine the most appropriate surgical strategy in the management of patients with major inflammatory complications of colonic diverticular disease.

MATERIALS AND METHODS

Out of 259 patients affected by complicated diverticular disease of the colon, 43 consecutive patients (16.6%) who underwent urgent or emergency surgical intervention for diverticular perforation during a 20-year period (1975-1994) were retrospectively analyzed. According to the changes in the surgical approach over the time, the series was divided into two groups: 1975-1985 group A (n = 23), 1986-1994 group B (n = 20). The clinical diagnosis was confirmed by operative and pathologic findings.

RESULTS

Out of 43 patients, 11 underwent derivative procedure and 32 resection. There were no significant differences among the two groups of patients according to sex ratio and mean age. The overall percentage of patients in group B who underwent resective procedure (100%) was significantly greater in comparison with that in group A (52%) (p < 0.001). Colostomy and drainage was employed only during the first period (30%)(vs group B, p < 0.05) and the proportion of patients who underwent primary resection and anastomosis was significantly higher during the second period (45%) (vs group A, p < 0.05).

CONCLUSIONS

It must be stressed that resection of the diseased segment at initial operation appears mandatory; one-stage procedure is indicated when infection is confined to the mesentery, while resection and anastomosis with covering colostomy (two-stage procedure) is preferable whenever peritoneal contamination has occurred. Hartmann's operation remains the procedure of choice in the patients presenting known impaired immunity or fecal contamination.

[Intraoperative colonoscopy: current indications]

From January 1987 to December 1991, 37 patients underwent intraoperative colonoscopy for several indications; these latter can be summarized in the need to define the site or extension of the lesions treated or detected by endoscopy before surgery. This procedure is therefore necessary in those cases in whom intraoperative endoscopy is likely to be useful in planning the surgical treatment. The use of intraoperative colonoscopy should be however considered complementary, but not substitutive, of the preoperative colonoscopy.

[Anatomo-surgical notes on transhiatal access in esophagectomy]

The Authors through an anatomic study on 20 cadavers specify the surgical procedure for transhiatal esophagectomy and describe the anatomical structures involved. The proper manoeuvres and artifices to avoid intraoperative accidents are suggested. Finally, the indications for this peculiar operation are discussed.

[Value of the study of occult fecal blood with Hemoccult II in 211 symptomatic patients controlled by total colonoscopy]

211 possibly neoplastic patients were given total colonoscopies after Hemoccult II test. The purpose of the experiment was to judge the value of occult faecal blood tests in the diagnosis of colonic neoplasias. Positive test results were obtained in 52 of whom 5 were found to have carcinomas and 17 polyps. Negative Hemoccult II results were produced in 159 patients of whom 6 had carcinomas and 54 polyps. All carcinoma patients with positive Hemoccult II results had rectal bleeding, 50% of those with negative tests results. Among polyp patients, 53% of those with Hemoccult II positive reported rectal bleeding, 60% of those with negative test results. Thus Hemoccult II is shown to be insufficiently sensitive to be of much value in mass screenings. It is suggested that a more sensitive test should be used for surveys of occult faecal blood.