Luciano Lenz

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.

Prospective study of bacteremia rate after elective band ligation and sclerotherapy with cyanoacrylate for esophageal varices in patients with advanced liver disease

CONTEXT Band ligation (BL) is the most appropriate endoscopic treatment for acute bleeding or prophylaxis of esophageal variceal bleeding. Sclerotherapy with N-butyl-2-cyanoacrylate (CY) can be an alternative for patients with advanced liver disease. Bacteremia is an infrequent complication after BL while the bacteremia rate following treatment with CY for esophageal varices remains unknown. OBJECTIVES To evaluate and compare the incidence of transient bacteremia between cirrhotic patients submitted to diagnostic endoscopy, CY and BL for treatment of esophageal varices. METHODS A prospective study comprising the period from 2004 to 2007 was conducted at Hospital of Universidade Federal de São Paulo, UNIFESP, SP, Brazil. Cirrhotic patients with advanced liver disease (Child-Pugh B or C) were enrolled. The patients were divided into two groups according treatment: BL Group (patients undergoing band ligation, n = 20) and CY Group (patients receiving cyanoacrylate injection for esophageal variceal, n = 18). Cirrhotic patients with no esophageal varices or without indication for endoscopic treatment were recruited as control (diagnostic group n = 20). Bacteremia was evaluated by blood culture at baseline and 30 minutes after the procedure. RESULTS After 137 scheduled endoscopic procedures, none of the 58 patients had fever or any sign suggestive of infection. All baseline cultures were negative. No positive cultures were observed after CY or in the control group - diagnostic endoscopy. Three (4.6 %) positive cultures were found out of the 65 sessions of band ligation (P = 0.187). Two of these samples were positive for coagulase-negative staphylococcus, which could be regarded as a contaminant. The isolated microorganism in the other case was Klebsiella oxytoca. The patient in this case presented no evidence of immunodeficiency except liver disease. CONCLUSIONS There was no significant difference in bacteremia rate between these three groups. BL or CY injection for non-bleeding esophageal varices may be considered as low-risk procedures regarding bacteremia even when performed on patients with advanced liver disease.

Comparative results of gastric submucosal injection with hydroxypropyl methylcellulose, carboxymethylcellulose and normal saline solution in a porcine model

CONTEXT Endoscopic mucosal resection is an established modality for excision of sessile lesions in the gastrointestinal tract. Submucosal fluid injection creates a cushion and may prevent thermal injury and perforation. OBJECTIVES This blind study investigated the performance of three different solutions to create submucosal fluid cushions in porcine stomach. METHODS Three solutions were injected in the stomach of nine pigs BR1: normal saline solution, carboxymethylcellulose 0.5% and hydroxypropyl methylcellulose 0.25%. In each pig, submucosal injections with 6 mL per test-solution were performed. One drop of methylene blue was added to all injections for better visualization. The time for the bleb to disappear was recorded. RESULTS The overall median time of visible submucosal cushion was 37 minutes (range 12-60 min) for hydroxypropyl methylcellulose, 31 minutes for carboxymethylcellulose (range 10-43 min) and 19 minutes for normal saline solution (range 8-37 min). There was no statistically significant difference neither between normal saline solution and carboxymethylcellulose (P = 0.146) nor carboxymethylcellulose and hydroxypropyl methylcellulose (P = 0.119) but the median duration of hydroxypropyl methylcellulose was significantly longer than normal saline solution (P = 0.039). CONCLUSIONS The length of hydroxypropyl methylcellulose submucosal fluid cushion is longer in comparison with normal saline solution. The median time for carboxymethylcellulose was not longer than normal saline solution. Hydroxypropyl methylcellulose, in the concentration of 0.25%, may be a durable alternative for submucosal injection.

Chronic radiation proctopathy: A practical review of endoscopic treatment

Chronic radiation proctopathy (CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbid-mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, potassium titanyl phosphate laser, neodymium:yttrium-aluminum-garnet laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation, cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising.

Review of Pancreatic Lesions in Von Hippel-Lindau Disease

Von Hippel-Lindaudisease (VHLD) is a rare hereditary tumor syndrome, inherited in autosomal dominant manner. Patients diagnosed with VHLD have a high risk of developing neoplasms of various organs (eyes, central nervous system, bone, kidney, adrenal glands, epididymis, broad ligament and pancreas). Due to its rarity, most of the physicians fail to properly diagnose it in time, and they might expose patients to a risk of unnecessary surgeries with important consequences in a long run. When this condition is diagnosed, lifelong follow-up is necessary. Pancreatic involvement it is seen in most patients with VHLD and various pancreatic lesions have been described, including cystic lesions (simple unilocular or serous microcystic or macro/micro-cystic adenomas), neuroendocrine tumors (NET), renal cell cancer metastasis and adenocarcinoma.

Pyloric Brunner’s gland hamartoma with atypical hyperplasia

Brunner’s gland hamartoma (BGH) is an extremely rare benign digestive tumor, generally located in the duodenal bulb. We report the case of a 51-year-old asymptomatic man with a large pedunculated BGH arising from the pylorus. It was successfully removed en bloc by endoscopic resection.