Nikos Stergiou

Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: A randomized, controlled trial

BACKGROUND Endoscopy with the patient under sedation with propofol requires careful monitoring of patient consciousness and vital signs to achieve the desired hypnotic effect without overdosage. Because level of consciousness is difficult to judge by clinical observation alone, electroencephalogram monitoring has been used to guide general anesthesia. METHODS Eighty consecutive patients (mean [SD] age 62 [14] years) undergoing ERCP for various indications were randomly allocated to 2 groups. In group A (n = 40), propofol sedation was guided by conventional monitoring (heart rate, blood pressure, oxygen saturation, electrocardiogram), whereas electroencephalogram monitoring was performed but not displayed to the physician who administered the drug. In group B (n = 40), electroencephalogram monitoring was displayed online and used to guide propofol administration to maintain a preselected sedation level. Procedure-related parameters, recovery time, and quality (postanesthesia recovery score), as well as patient cooperation and tolerance for the procedure (visual analog scale) were prospectively assessed. RESULTS The groups were comparable with regard to demographic, clinical, and procedure-related parameters. Mean propofol dose was significantly lower in group B than in group A (respectively, 290 [158] mg vs. 374 [166] mg; p = 0.02). The mean decrease in arterial blood pressure was significantly lower in group B than in group A (respectively, 11 [6] mm Hg vs. 14 [7] mm Hg; p < 0.05). Clinically relevant changes in vital signs to below critical values were observed in both groups, albeit infrequently. Efficacy of sedation was also rated similar in both groups, whereas mean recovery time was significantly faster in group B than in group A (respectively, 16 [7] minutes vs. 20 [8] minutes; p = 0.02). Accordingly, the recovery score tended to be better in group B compared with group A (respectively, 8.4 [1.0] points vs. 8.0 [0.9] points; p = 0.06). The predefined target level of sedation was maintained during 75% of the procedure time in group B but in only 58% of the time in group A (p < 0.05), and deeper sedation levels were achieved significantly more often in group B patients compared with group A patients (p < 0.05). CONCLUSION Electroencephalogram monitoring enables more effective titration of propofol dosage for sedation during endoscopy and is, therefore, associated with faster patient recovery.

Hemorrhoidal elastic band ligation with flexible videoendoscopes: a prospective, randomized comparison with the conventional technique that uses rigid proctoscopes

BACKGROUND Elastic band ligation by means of a rigid proctoscope is the treatment of choice for patients with symptoms caused by internal hemorrhoids of grade 2 to 3. In contrast to the flexible videoendoscope, the rigid proctoscope has limited maneuverability, has a narrower field of view, and does not allow adequate documentation. Therefore, a randomized trial was conducted to compare the safety and the efficacy of conventional elastic band ligation with videoendoscopic elastic band ligation. METHODS A total of 100 consecutive patients (mean age 47 [12] years) with chronically bleeding grade 2 or 3 internal hemorrhoids were randomized to elastic band ligation or videoendoscopic elastic band ligation. For videoendoscopic elastic band ligation, a reusable multiband ligator was attached to the end of a therapeutic upper videoendoscope. From one to 3 bands were placed per session in both groups. Re-treatment was performed every 2 to 3 weeks in both groups until cessation of bleeding and eradication of the hemorrhoids (at least grade 2) were achieved. Thereafter, the patients were followed to assess complications and efficacy. Recurrent bleeding was considered a treatment failure. RESULTS To achieve the desired therapeutic aims, a significantly lower number of treatment sessions was required in the videoendoscopic elastic band ligation group (1.8 [0.8] vs. 2.4 [0.9]; p < 0.01) and the total number of bands applied was significantly less (2.8 [1.1] vs. 3.7 [1.4]; p < 0.01). Pain was noted after ligation by 25% of patients in the elastic band ligation group compared with 27% of those who had videoendoscopic elastic band ligation. However, analgesic medications were required in only 7% after elastic band ligation and 9% after videoendoscopic elastic band ligation (NS). Post-ligation bleeding that had to be treated endoscopically occurred in 3.5% of the patients of the elastic band ligation group and 3.2% of those in the videoendoscopic elastic band ligation group (NS). Blood transfusion was not required. At a median follow-up of 12 months, there was no recurrence of bleeding in 40 patients (80%) in the conventional elastic band ligation group vs. 43 (86%) in the videoendoscopic elastic band ligation (NS). CONCLUSIONS The long-term efficacy and safety of conventional elastic band ligation and videoendoscopic elastic band ligation are highly comparable. However, when videoendoscopic elastic band ligation is performed, significantly fewer treatment sessions are required.

Endoscopic pancreatic duct stenting for relief of pancreatic cancer pain.

Introduction Little is known about the effects of endoscopic pancreatic duct (PD) decompression in patients with ‘obstructive type’ pain from pancreatic carcinoma. Methods Twenty patients with unresectable carcinoma of the pancreas, PD obstruction and postprandial epigastric pain were enrolled. The pain intensity, opioid dose and quality-of-life index were documented pre-treatment and at 4-weekly intervals. PD stenting was attempted in all patients. PD stent change was performed if biliary stents had to be changed or intense pain relapsed. Results Endoscopic PD drainage was successful in 19/20 patients by placement of a 7 F (n=9) or 10 F (n=10) plastic stent. Median follow-up was 16 weeks. Two patients were alive at the end of follow-up. Eleven patients received gemcitabine chemotherapy. The pre-interventional pain score was 6.7±0.9 points and decreased to 3.1±1.4 points at 4 weeks (P<0.001). It remained lowered significantly at 8/12 weeks and at the final visit (4.2±1.5 points, n=13). The mean pre-stenting fentanyl dose was 85.5±34.7 μg/h, and it was decreased to 57.9±39.1 μg/h after 4 weeks (P<0.01), 60.5±38.9 μg/h after 8 weeks and 64.1±39.8 μg/h (P<0.01 versus pre-treatment) after 12 weeks but increased to 82.7±41.3 μg/h (NS) at the final visit. The quality-of-life index improved 4 weeks after stenting (from 4.8±1 to 6.2±1.5 points, P<0.01) but was lowered to 5.5±2.3 points at 12 weeks (NS). The response was independent of stent diameter and chemotherapy. Conclusion PD stenting achieved significant pain relief and short-term improvement of the quality of life in the majority of patients with PD obstruction due to pancreatic carcinoma.

Endoscopic Resection of Submucosal Tumors of the Esophagus. A Prospective Case Series

Endoscopic Resection of Submucosal Tumors of the Esophagus. A Prospective Case Series Till Wehrmann, Ksenia Martchenko, Andrea Riphaus, Nikos Stergiou The introduction of endoscopic ultrasonography (EUS) and of endoscopic mucosal resection offered a new alternative to simple observation or surgical resection for the management of esophageal submucosal tumors. Methods: During a 4-year period endoscopic resection was attempted in 17 consecutive patients (mean age, 53611 years, 8 females) with esophageal submucosal tumors confirmed by endoscopy and miniprobe-EUS (20 MHz). The mean tumor diameter was 14611 mm (8-34 mm). Former EUS-guided cytology was benign in 11 cases, however, endoscopic resection was intended in most cases also for diagnostic purposes. Several patients were symptomatic (retrosternal pain, n=4, dysphagia, n=3, recurrent bleeding, n=2) but most tumors had been detected incidentally. Results: In the majority of cases the tumor was ligated with a rubber band and than resected with a snare (n=9), in the other cases simple snare resection (‘‘lift and cut’’, n=5) or cap resection (n=3) was performed. A macroscopically complete endoscopic resection could be achieved in 16/17 patients, the remaining patient was managed surgically. Endoscopic hemostasis was necessary in 7 cases (41%, always successful) and blood transfusions were not required. No other side effects occurred. Histology revealed a granular cell tumor in 11 patients, a leiomyoma in 3 cases, and a lipoma as well as a stromal tumor in one patient each, respectively. All tumors were judged histologically as benign and a microscopically complete resection (R0) was obtained in all cases, with the exception of the patient with the stromal tumor. Therefore, surgical resection was necessary in only two of the 17 patients (12%). During a prospective follow-up of 1267 months tumor reccurrence was not detected in any case. Conclusions: Endoscopic resection of esophageal submucosal tumors is safe and effective. The probability to achieve a curative treatment (R0-resection with benign histology) is high (> 80%), especially if the tumor diameter is < 3 cm. *W1501 Endoscopic Treatment of Anastomotic Strictures Following Resection of Esophageal CA: Increased Success Using Submucosal Corticosteroid Injection Marc F. Catalano, Suku George, Miriam Thomas, Joseph E. Geenen Esophageal CA is the 3rd leading digestive malignancy in the U.S. Most pts have advanced disease at Dx. Surgical resection remains the only effective curative option. Complications include anastomotic strictures approaching 10%. Few successful, long-term endoscopicRx options have been reported. AIM:Determine the safety and effectiveness of endoscopic balloon dilatation of anastomotic strictures following esophagectomy. METHOD: 15 pts (12 M, 3 W, age 49-73) presented with symptoms of dysphagia w or w/o odynophagia, 6wks-8mo following esophagectomy. All pts had esophagectomy for T1-T3 disease. Barium x-ray studies following surgery demonstrated anastomotic strictures prior to referral for endotherapy. Endotherapy was performed using (8-20mm) CRE through-the-scope balloon at 45-90 PSI at 1-min intervals and repeated as necessary. In cases whereby advancement was not initially possible using CRE balloon, guidewire Savary dilation was performed. Pts with refractory strictures, despite repeated dilation, underwent steroid injection (40g Kenalog) at the stricture site. Rx success was defined as resolution of dysphagia. RESULTS: All pts had anastomotic strictures#5mm that failed to allow passage of the standard upper scope. All dilations were successfully completed under fluoroscopy. Pts underwent 4-10 dilation sessions at 2-4 wk intervals (mean 5.5 sessions). 4 pts required guidewire dilation prior to balloon dilation (inability to advance the CRE balloons beyond the stricture). 7 pts had Kenalog injection at the anastomotic site (4 quadrants) because of refractory strictures following the initial dilatation. All pts had resolution of symptoms following complete serial dilation. All were placed on high-dose PPI following initial endoscopic dilation. 3 stricture recurrences occurred at 2, 4 and 9 mo and were treated successfully by repeat dilation with the use of Kenalog (good long-term success). No complications were encountered during therapy. CONCLUSION: Anastomotic strictures following esophagectomy for adenocarcinoma is an infrequent postsurgical complication. Endoscopic balloon dilation is an effective nonsurgical method for Rx of these anastomotic strictures. Up to 50% of these anastomotic strictures may be refractory to simple balloon dilation and will require concomitant steroid injection for long-term success.