Wichit Srikureja

Experience of intravenous sedation for pediatric gastrointestinal endoscopy in a large tertiary referral center in a developing country

Background:  The aim of this study was to evaluate the clinical efficacy of intravenous sedation for pediatric gastrointestinal endoscopy (GIE) at a tertiary care teaching hospital in a developing country.

Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy.

Endoscopic ultrasound‐guided fine‐needle aspiration biopsy (EUS‐guided FNAB) is highly sensitive and specific in cytologic diagnosis and clinical staging of malignant neoplasms of the gastrointestinal tract, pancreas, liver, and lymph nodes. However, no study has been performed to evaluate its accuracy, sensitivity, specificity, and the cytomorphologic features of suspected primary ampullary tumors.

Pathological complete response after neoadjuvant chemotherapy with trastuzumab-containing regimen in gastric cancer: a case report.

We report a 49-year-old Chinese male with locally advanced gastric adenocarcinoma achieving pathological complete response after neoadjuvant chemotherapy with trastuzumab-containing regimen. He underwent esophagogastroduodenoscopy in September 2009, which revealed a 2-cm gastric ulcer on the lesser curvature proximal to angularis. Biopsy of gastric ulcer showed moderately differentiated adenocarcinoma with overexpression of human epidermal growth factor receptor 2 (HER2) by immunohistochemistry and fluorescence in situ hybridization. Further workups with endoscopic ultrasound, computed tomography and positron emission tomography staged his cancer as T3N1M0. He received 3 cycles of neoadjuvant chemotherapy consisting of trastuzumab, oxaliplatin, docetaxel and capecitabine without severe toxicities except grade 2 diarrhea near the completion of cycle 3 requiring discontinuation of capecitabine. Afterwards, he received total gastrectomy with extended D2 lymph node dissections showing pathological complete response. He went on to receive 3 more cycles of chemotherapy postoperatively. The role of trastuzumab as a part of perioperative therapy in gastric cancer overexpressing HER2 is worth further investigation.

Dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography.

BACKGROUND In general, the dose requirement and complications of propofol are lower when used in the diluted form than in the undiluted form. The aim of this study was to determine the dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography. METHODS Eighty-six patients were randomly assigned to either group D (diluted propofol) or U (undiluted propofol). All patients were sedated with 0.02-0.03 mg/kg midazolam (total dose ≤2 mg for age <70 years and 1 mg for age ≥70) and 0.5-1 μg/kg fentanyl (total dose ≤75 μg for age <70 and ≤50 μg for age ≥70). Patients in group U (42) were sedated with standard undiluted propofol (10 mg/mL). Patients in group D (44) were sedated with diluted propofol (5 mg/mL). All patients in both groups were monitored for the depth of sedation using the Narcotrend system. The primary outcome variable was the total dose of propofol used during the procedure. The secondary outcome variables were complications during and immediately after the procedure, and recovery time. RESULTS All endoscopies were completed successfully. Mean propofol doses per body weight and per body weight per hour in groups D and U were 3.0 mg/kg, 6.2 mg/kg per hour and 4.7 mg/kg, 8.0 mg/kg per hour, respectively. The mean dose of propofol, expressed as total dose, dose/kg or dose/kg per hour and the recovery time were not significantly different between the two groups. Sedation-related adverse events during and immediately after the procedure were higher in group U (42.9%) than in group D (18.2%) (P=0.013). CONCLUSIONS Propofol requirement and recovery time in the diluted and undiluted propofol groups were comparable. However, the sedation-related hypotension was significantly lower in the diluted group than the undiluted group.

Topical viscous lidocaine solution versus lidocaine spray for pharyngeal anesthesia in unsedated esophagogastroduodenoscopy

BACKGROUND AND STUDY AIMS Pharyngeal anesthesia using topical lidocaine is generally used as pretreatment for unsedated esophagogastroduodenoscopy (UEGD). The aim of this study was to compare and evaluate the clinical efficacy of topical viscous lidocaine solution and lidocaine spray when each is used as a single agent for UEGD. PATIENTS AND METHODS Patients were randomized into the viscous lidocaine (V) group (n = 930) or the lidocaine spray (S) group (n = 934). The total dose of lidocaine was not higher than 5 mg/kg. The primary objective was to measure the successful completion rate of the endoscopy. The secondary objectives were to assess patient and endoscopist satisfaction, procedural pain, patient tolerance, ease of intubation, and adverse events. RESULTS The procedure was successfully completed in 868 patients from group V (93.3 %) and 931 patients from group S (99.7 %; P < 0.001). Patients and endoscopists reported a higher degree of satisfaction in group S than group V ( P < 0.0001). Procedural pain score in group S was significantly lower than in group V ( P < 0.0001). The endoscopist rated patients in group S as having better tolerance and ease of intubation than those in group V ( P = 0.0004 and P = 0.002, respectively). Adverse events occurred in 370 patients in group V and 316 patients in group S ( P = 0.002). These were mainly transient changes in vital signs including hypertension, tachycardia, and bradycardia. CONCLUSIONS The use of lidocaine spray in UEGD was shown to result in a higher procedural completion rate, greater ease of intubation, and greater patient and endoscopist satisfaction. Topical lidocaine spray may be a better form of pharyngeal anesthesia than viscous lidocaine solution in UEGD.

Endoscopic palliation of pancreatic adenocarcinoma.

Purpose of review Endoscopic therapies have become an indispensable modality in the treatment and palliation of complications from pancreatic adenocarcinoma. This review focuses on treatment of biliary obstruction, malignant gastric outlet obstruction, and intractable abdominal pain resulting from unresectable pancreatic adenocarcinoma. Novel and emerging endoscopic approaches are also briefly discussed. Recent findings Endoscopic placement of a biliary stent is the modality of choice for palliation of biliary obstruction. Biliary self-expanding metal stents should be placed if expected survival is more than 6 months and plastic stents if expected survival is less than 6 months. For endoscopic palliation of gastric outlet obstruction, enteral self-expanding metal stents should be placed. Biliary self-expanding metal stents should be considered prior to the placement of a duodenal stent. Palliation of intractable abdominal pain can safely be performed with endoscopic ultrasound-guided celiac plexus neurolysis using bupivacaine and absolute alcohol. Exciting novel endoscopic approaches are being evaluated especially in the area of drug-eluted biliary stents, endoscopic creations of enteral anastomoses, and endoscopic ultrasound-guided injection of gene vectors. Summary The frontier of endoscopic palliative therapies for pancreatic adenocarcinoma is expanding. Clinical trials are needed to evaluate novel endoscopic approaches.

Original article. Intravenous sedation for gastrointestinal endoscopy in very elderly patients of Thailand

Abstract Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians. Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (>86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (<86 years old) Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic personnel in the endoscopy room. The cohort was divided into three groups, <65 years old (group 1), 65-85 years old (group 2), and >86 years old (group 3). Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p <0.001). Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p <0.001). Transient hypotension was the main complication across all aged groups. Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

Utility of Diphenhydramine for Conscious Sedation During Colonoscopy

Utility of Diphenhydramine for Conscious Sedation During Colonoscopy Wichit Srikureja, Yoshi Mineyama, John D. McCracken, David Condon Purpose: With the recent black box warning of life-threatening arrhythmia on droperidol, there is a need to look for a safer adjunct medication for sedation. We assessed the utility of intravenous diphenhydramine as an adjunct pre-medication in routine colonoscopy in a prospective, randomized, double-blinded, and placebocontrolled trial. Methods: Consecutive patients referred for colonoscopy were randomized to receive either 50mg diphenhydramine or saline placebo. The study medicationwasgiven intravenously and immediately followedby25mgofmeperidine and1mgofmidazolam.After threeminutes, patient receivedadditionalmeperidineor midazolam at the discretion of the endoscopist. The procedure could then be started. Procedure and recovery times, number of interruptions, total medication dosages, andadverse eventswererecorded.Theendoscopist and thesedatingnurse assessed the quality of the sedation on a 10-point scale (1=poor, 10=excellent). Upon discharge and at twenty-four hour post procedure, the patients assessed the quality of sedation quantitatively using the above scale and qualitatively through questionnaires. Results:A total of88patientswere randomizedwith equal number ineachgroup.The mean age was 60 6 11.5 years. Fifty-two patients (59.1%) were male. Table 1 summarizes thecomparisonofmeanvariables in eachgroup.Atdischarge,patients in the diphenhydramine group were more likely to feel drowsy (p=0.053), less likely to be back to usual self (p=0.042), and less likely to recollect the procedure (p=0.026). These differences were not seen at twenty-four hour.No adverse events were noted in either group. Conclusion: Although diphenhydramine is well tolerated with additional amnesic effect, it does not increase the quality of sedation, shorten the procedure time, or reduce thestandard sedativesdosageswhenusedasanadjunctpremedication in patients undergoing routine colonoscopy. Its role in patients difficult to sedate or in prolonged procedure such as ERCP remained to be confirmed. **198 Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) of Pancreatic Cysts Linda S. Lee, John Saltzman, William R. Brugge, Christopher C. Thompson Purpose: EUS-FNA is generally accepted as a safe endoscopic procedure. However, data regarding complications after EUS-FNA of pancreatic cysts is limited and conflicting. The aim of this study is to ascertain the complication rates of EUS-FNA of pancreatic cysts and related risk factors. Methods: EUS-FNA of 684 pancreatic cysts at two academic institutions between 3/1996 and 10/2003were retrospectively reviewed. Following EUS-FNA, patients were tracked using discharge summaries, clinic logs, laboratory and radiologic data in the computerized hospital systems. The following data were gathered: cyst diagnosis, size, septations, degree of aspiration, use of prophylactic antibiotics, complications, and performance of ERCP on the same date. For complications, further data were collected: symptoms, temperature, hospitalization, length of hospital stay (LOS), laboratory data, and treatment during hospitalization. Results: Fifteen nonfatal complications were identified (2%, 15/684): 6 pancreatitis, 2 selflimited retroperitoneal bleeds, 2 infections, and 4 abdominal pain. Fourteen required hospitalization with an average LOS 4.6 days (range 1-14). The following predictors were examined but were not statistically significant (patients with complications vs. without complications): diagnosis (73% vs. 62% cystic neoplasm, 7% vs. 10% pseudocyst, 7% vs. 14% IPMT, 0% vs. 14% cancer), size (30.9 mm vs. 25.8 mm), septations (67% vs. 49% unilocular, 33% vs. 38% multilocular, 0% vs. 13% solid-cystic), same day ERCP (13% vs. 8%), and use of prophylactic antibiotics (100% vs. 89%). There was no increased rate of pancreatitis in patients undergoing both EUS-FNA and ERCP (n=56) (1.8%) on the same day versus only EUS-FNA (n=628) (0.8%). In a subset analysis of 76 EUS-FNAof pancreatic cysts not given prophylactic antibiotics, no complications were identified. Average cyst size was significantly smaller than the 608 cysts aspirated with prophylactic antibiotics (19.8 mm vs. 26.8 mm, p=0.003). Conclusions: In this largest reported experience of EUS-guided pancreatic cyst aspiration, the complication rate is low (2%). Small pancreatic cysts were safely aspirated without the use of prophylactic antibiotics. Cyst diagnosis, size, septations, mass, and performance of same day ERCP do not appear to be risk factors for the development of complications.

Acute food impaction: a rare presentation and complication of heterotopic gastric mucosa in the proximal esophagus

was absent, and esophageal and gastric varices were excluded by endoscopy (EGD). Due to significant impairment in quality of life and increased risk of medical complications from persistent HE, the patient and his wife were consented for an experimental procedure to reduce flow in his splenorenal shunt. Procedure: The left renal vein and splenorenal conduit were accessed via percutaneous catheter. A Simon-Nitinol Filter was deployed into the shunt with the tip directed toward the renal vein. Six 10-12mm metal coils were deployed into the filter. Angiographic flow rate was subsequently reduced. Final hepatic vein pressure gradient remained unchanged at 28mmHg at the end of the procedure. Shunt flow could not be visualized on contrast ultrasound the following day. Two weeks later, ultrasound revealed improved hepatopetal flow within the portal vein and no ascites, and EGD revealed trace esophageal varices without bleeding. HE has improved without requirement for admission while on maintenance oral lactulose. Discussion: Spontaneous portosystemic shunting should be suspected in patients with cirrhosis, persistent HE, and lack of significant ascites or esophagogastric varices. Persistent HE refractory to medical therapy can be safely controlled by percutaneous embolization of portosystemic shunts.