Alexandre Oliveira Ferreira

Sedation in gastrointestinal endoscopy: Where are we at in 2014?

Gastrointestinal endoscopies are invasive and unpleasant procedures that are increasingly being used worldwide. The importance of high quality procedures (especially in colorectal cancer screening), the increasing patient awareness and the expectation of painless examination, increase the need for procedural sedation. The best single sedation agent for endoscopy is propofol which, due to its pharmacokinetic/dynamic profile allows for a higher patient satisfaction and procedural quality and lower induction and recovery times, while maintaining the safety of traditional sedation. Propofol is an anesthetic agent when used in higher doses than those needed for endoscopy. Because of this important feature it may lead to cardiovascular and respiratory depression and, ultimately, to cardiac arrest and death. Fueled by this argument, concern over the safety of its administration by personnel without general anesthesia training has arisen. Propofol usage seems to be increasing but its still underused. It is a safe alternative for simple endoscopic procedures in low risk patients even if administered by non-anesthesiologists. Evidence on propofol safety in complex procedures and high risk patients is less robust and in these cases, the presence of an anesthetist should be considered. We review the existing evidence on the topic and evaluate the regional differences on sedation practices.

Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis

Background and aims: Submucosal injection is standard practice in endoscopic mucosal resection of gastrointestinal lesions. Several solutions are used. Our aim was to systematically review their efficacy and safety. Patients and methods: We performed a systematic review and meta-analysis using a random effects model of randomized controlled trials (RCTs) from MEDLINE. Studies in animal models were qualitatively assessed for efficacy and safety. Results: In total, 54 studies were qualitatively assessed. Eleven RCTs were analyzed, two of which were on endoscopic submucosal dissection (ESD). The quantitative synthesis included nine RCTs on endoscopic mucosal resection (EMR), comprising 792 subjects and 793 lesions. Mean lesion size was 20.9u200amm (range 8.5u200a–u200a46u200amm). A total of 209 lesions were randomized to sodium hyaluronate (SH) vs normal saline (NS), 72 to 50u200a% dextrose (D50) vs NS, 82 to D50 vs SH, 43 to succinylated gelatin, 25 to hydroxyethyl starch and 36 to fibrinogen. In total, 385 were randomized to NS as controls. NS and SH are the best studied solutions and seem to be equally effective in achieving complete resection (OR 1.09; 95u200a%CI 0.82, 1.45). No solution was proven to be superior in complete resection rate, post-polypectomy bleeding or coagulation syndrome/perforation incidence. Many solutions have been tested in animal studies and most seem more effective for mucosal elevation than NS. Conclusions: There are several solutions in clinical use and many more under research, but most are poorly studied. SH seems to be clinically equivalent to NS.u200aThere are no significant differences in post-polypectomy complications. Larger RCTs are needed to determine any small differences that may exist between solutions.

Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low risk patients: results of a noninferiority randomized controlled trial

BACKGROUND AND STUDY AIMSnPropofol provides the best sedation in colonoscopy. The safety of non-anesthesiologist administration of propofol (NAAP) is still a matter of debate. The aim of the current study was to evaluate sedation safety, colonoscopy quality, and patient satisfaction with NAAP.nnnPATIENTS AND METHODSnThe study was a single-blinded, noninferiority, randomized controlled trial comparing NAAP (Group A) with anesthesiologist-administered sedation (Group B) performed at a single academic institution. Patients (18u200a-u200a80 years) who underwent colonoscopy and were at low anesthetic risk (American Society of Anesthesiologists class Iu200a-u200aII) were included. The primary end point was the incidence of adverse events. Secondary end points were propofol dose, patient satisfaction and pain, colonoscopy quality indicators, and procedure and recovery times.nnnRESULTSnA total of 277 patients were included in the analysis. The incidence of adverse events was 39.3u200a% in Group A and 39.0u200a% in Group B (absolute difference -u200a0.3u200a%, 95u200a% confidence interval [CI]u200a-u200a12.0u200a% to 11.4u200a%; Pu200a=u200a0.959). There were no sentinel adverse events. The following interventions (Group A vs. Group B) were necessary: atropine administration (0u200a% vs. 5.5u200a%; Pu200a=u200a0.004); airway repositioning (8.7u200a% vs. 4.7u200a%; Pu200a=u200a0.196); increased oxygen administration (6.7u200a% vs. 3.9u200a%; Pu200a=u200a0.317), and increased fluid rate (2.7u200a% vs. 0.8u200a%; Pu200a=u200a0.379). There were no differences in cecal intubation and adenoma detection rates. Recovery times were longer in Group B (58u200a±u200a33 vs. 67u200a±u200a29 minutes; Pu200a=u200a0.032). There were no differences in mean propofol dose, withdrawal time, painless colonoscopy, satisfaction, and amnesia. All but two patients (Group B) were willing to repeat the colonoscopy.nnnCONCLUSIONSnNAAP is equivalent to anesthesiologist-administered sedation in the rate of adverse events in a low risk population.nnnTRIAL REGISTRATIONnClinicalTrials.gov (NCT02067065).

Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines

1: u2002ESGE suggests using contrast-enhanced computed tomography (CT) as the first-line imaging modality on admission when indicated and up to the 4th week from onset in the absence of contraindications. Magnetic resonance imaging (MRI) may be used instead of CT in patients with contraindications to contrast-enhanced CT, and after the 4th week from onset when invasive intervention is considered because the contents (liquid vs. solid) of pancreatic collections are better characterized by MRI and evaluation of pancreatic duct integrity is possible. Weak recommendation, low quality evidence. 2: u2002ESGE recommends against routine percutaneous fine needle aspiration (FNA) of (peri)pancreatic collections. Strong recommendation, moderate quality evidence. FNA should be performed only if there is suspicion of infection and clinical/imaging signs are unclear. Weak recommendation, low quality evidence. 3: u2002ESGE recommends initial goal-directed intravenous fluid therapy with Ringers lactate (e.u200ag. 5u200a-u200a10u200amL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4: u2002ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5: u2002ESGE recommends invasive intervention for patients with acute necrotizing pancreatitis and clinically suspected or proven infected necrosis. Strong recommendation, low quality evidence.ESGE suggests that the first intervention for infected necrosis should be delayed for 4xa0weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6: u2002ESGE recommends performing endoscopic or percutaneous drainage of (suspected) infected walled-off necrosis as the first interventional method, taking into account the location of the walled-off necrosis and local expertise. Strong recommendation, moderate quality evidence. 7: u2002ESGE suggests that, in the absence of improvement following endoscopic transmural drainage of walled-off necrosis, endoscopic necrosectomy or minimally invasive surgery (if percutaneous drainage has already been performed) is to be preferred over open surgery as the next therapeutic step, taking into account the location of the walled-off necrosis and local expertise. Weak recommendation, low quality evidence. 8: u2002ESGE recommends long-term indwelling of transluminal plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. Lumen-apposing metal stents should be retrieved within 4xa0weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence.

Adenoma Detection Rate: I Will Show You Mine if You Show Me Yours

Background: Colorectal cancer (CRC) is the first cause of cancer-related mortality in Portugal. CRC screening reduces disease-specific mortality. Colonoscopy is currently the preferred method for screening as it may contribute to the reduction of CRC incidence. This beneficial effect is strongly associated with the adenoma detection rate (ADR). Aim: Our aim was to evaluate the quality of colonoscopy at our unit by measuring the currently accepted quality parameters and publish them as benchmarking indicators. Methods: From 5,860 colonoscopies, 654 screening procedures (with and without previous fecal occult blood testing) were analyzed. Results: The mean age of the patients was 66.4 ± 7.8 years, and the gender distribution was 1:1. The overall ADR was 36% (95% confidence interval [CI] 32-39), the mean number of adenomas per colonoscopy was 0.66 (95% CI 0.56-0.77), and the sessile serrate lesion detection rate was 1% (95% CI 0-2). The bowel preparation was rated as adequate in 496 (76%) patients. The adjusted cecal intubation rate (CIR) was 93.7% (95% CI 91.7-95.8). Most colonoscopies were performed under monitored anesthesia care (53%), and 35% were unsedated. The use of sedation (propofol or midazolam based) was associated with a higher CIR with an odds ratio of 3.60 (95% CI 2.02-6.40, p < 0.001). Conclusion: Our data show an above-standard ADR. The frequency of poor bowel preparation and the low sessile serrated lesion detection rate were acknowledged, and actions were implemented to improve both indicators. Quality auditing in colonoscopy should be compulsory, and while many units may do so internally, this is the first national report from a high-throughput endoscopy unit.

Endoscopic sedation and monitoring practices in Portugal: a nationwide web-based survey.

Background National surveys have been used to obtain information on sedation and monitoring practices in endoscopy in several countries. Aims To provide data from Portugal and query the Portuguese endoscopists on nonanesthesiologist administration of propofol. Materials and methods A 31-item web survey was sent to all 490 members of the Portuguese Society of Gastroenterology. Results A total of 129 members (26%) completed the questionnaire; 57% worked in both public and private practice. Most performed esophagogastroduodenoscopy without sedation (public − 70%; private − 57%) and colonoscopies with sedation (public − 64%; private − 69%). Propofol was the most commonly used agent for colonoscopy, especially in private practice (52 vs. 33%), and it provided the best satisfaction (mean 9.6/10). A total of 94% chose propofol as the preferred sedation for routine colonoscopy. Nonanesthesiologist administration of propofol was performed only by four respondents; however, 71% reported that they would consider its use, given adequate training. Pulse oximetry is monitored routinely (99%); oxygen supplementation is administered by 81% with propofol and 42% with traditional sedation. Most (82%) believed that propofol sedation may increase the uptake of endoscopic screening for colorectal cancer. Conclusion The use of sedation is routine practice in colonoscopy, but not esophagogastroduodenoscopy. The preferred agent is propofol and it is used almost exclusively by anesthesiologists.

Increased risk for metachronous gastric adenocarcinoma following gastric MALT lymphoma-A US population-based study

Background Gastric mucosa-associated lymphoid tissue lymphoma (gMALT) and gastric adenocarcinoma (GC) are long-term complications of chronic Helicobacter pylori (HP) gastritis. Treatment of HP infection induces remission in most patients with gMALT. Endoscopic follow-up is not currently endorsed after complete remission. However, the risk of GC in these patients is unclear. Objective The objective of this study is to estimate GC risk in gMALT patients. Methods The National Cancer Institute Surveillance, Epidemiology and End Results 13 (SEER) database-Nov 2014 Sub (1992–2012) was used to identify adult patients diagnosed with gMALT between 1992 and 2012. The standardized incidence ratio of second primary GC after a latency period of 12 months was calculated and compared to a reference SEER cohort of identical age, sex and time period. The risk of GC in these patients was also stratified by latency period (five years) and age. Results We identified 2195 cases of gMALT lymphoma, and 20 (0.91%) of them subsequently developed GC with a relative risk (RR) of 4.32 (95% CI 2.64–6.67) compared to the American population. The median latency time was five years and the risk was maintained afterward (RR 4.92, 95% CI 2.45–8.79). When stratified by age group the risk was highest for the 45–64 group (RR 14.04, 95% CI 5.64–28.93). Conclusion gMALT lymphoma is associated with an increased risk of metachronous gastric adenocarcinoma. The risk is still present after more than five years of follow-up. Further studies may clarify the most adequate follow-up strategy.

Colorectal Cancer Awareness: The Gastroenterology Resolution for the Future

and raise public awareness to promote screening, as it is in their best interest to increase cost-effective preventive measures. Unfortunately, in Portugal, this role is mainly assumed by medical and patient societies, such as the Portuguese Society of Gastroenterology or the Portuguese Society of Digestive Endoscopy. These associations use traditional media and, more recently, social media to convey these important messages. However, these actions have a limited penetration, and in a country without a population-based screening program in place, without responsible insurance companies who fail to focus on sustainability and long-term customer retention, it rests on the medical doctors, especially gastroenterologists and general practitioners (GPs), to take the opportunity to inform patients in each individual interaction about the risks of CRC and the screening options available. In Portugal, there is a paucity of data regarding population screening adherence and, moreover, regarding personal preferences and knowledge. In the current edition of GE – Portuguese Journal of Gastroenterology, Teixeira et al. [7], from the Centro Hospitalar de Setúbal in Portugal, try to fill in this gap and report their valuable experience and the data gathered during a local awareness campaign designed and conducted by gastroenterologists and associated health professionals. Their aim was mainly to raise awareness by direct interaction with the public but

Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis

Introduction: The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients. Aim: The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis. Material/Methods: A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography. Results: Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%. Discussion and Conclusions: Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.

The Good, the Not So Bad, and the Ugly

Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures; Serviço de Gastrenterologia, Centro Hospitalar do Algarve, Portimão; and Serviço de Gastrenterologia – Hospital Beatriz Ângelo, Loures, Portugal 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 Question: A 50-year-old man presented to the emergency room after an episode of hematemesis with hemodynamic instability and syncope. His past medical history was relevant for active smoking, a noncomplicated duodenal ulcer 10 years ago, and anemia for which he was treated with oral iron in the past oral iron. He denied recent consumption of nonsteroidal anti-inflammatory drugs, excess alcohol intake, or other further symptoms. On physical examination he was tachycardic (120 bpm) with a blood pressure of 100/60 mm Hg. He was pale and presented mild tenderness on abdomen palpation. The remaining examination was unremarkable. Blood tests revealed a hemoglobin of 6.7 g/dL. Further laboratory evaluation was unremarkable. After adequate fluid resuscitation, red blood cell transfusion and pantoprazole bolus, the patient underwent videoendoscopy (Figure A). Biopsies were taken. Compute tomography (CT) of the thorax was performed afterward (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 104 105 106 107 108 109 110 Conflicts of interest The authors disclose no conflicts.