Gustavo F. Gomes

Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl

BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.

Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices.

AIM To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane (NBCM) as a prophylactic treatment for gastric varices (GV) bleeding. METHODS This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013. Patients with portal hypertension (PH) and GV, with no active gastrointestinal bleeding, were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution. Initial diagnosis of GV was based on endoscopy and confirmed with endosonography (EUS); the same procedure was used after treatment to confirm eradication of GV. After puncturing the GV with a regular injection needle, 1 mL of undiluted NBCM was injected intranasally into GV. The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected. Patients were followed clinically and evaluated with endoscopy at 3, 6 and 12 mo. Later follow-ups were performed yearly. The main outcome measures were efficacy (GV eradication), safety (adverse events related to cyanoacrylate injection), recurrence, bleeding from GV and mortality related to GV treatment. RESULTS A total of 20 patients (15 male) with PH and GV were enrolled in the study and treated with undiluted NBCM injection. Only 2 (10%) patients had no esophageal varices (EV); 18 (90%) patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study. The patients were followed clinically and endoscopically for a median of 31 mo (range: 6-40 mo). Eradication of GV was observed in all patients (13 patients were treated with 1 session and 7 patients with 2 sessions), with a maximum injected volume of 2 mL NBCM. One patient had GV recurrence, confirmed by EUS, at 6-mo follow-up, and another had late recurrence with GV bleeding after 35 mo of follow-up; overall, GV recurrence was observed in 2 patients (10%), after 6 and 35 mo of follow-up, and GV bleeding rate was 5% (1 patient). Mild epigastric pain was reported by 3 patients (15%). No mortality or major complications, including embolism, or damage to equipment were observed. CONCLUSION Endoscopic injection with NBCM, without lipiodol, may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.

Acute inflammatory response to transgastric natural orifice transluminal endoscopic surgery peritoneoscopy: An experimental study in swine

OBJECTIVE: To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy. METHODS: This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h. RESULTS: All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups. CONCLUSIONS: Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.