Bispectral index monitoring as an adjunct to nurse-administered combined sedation during endoscopic retrograde cholangiopancreatography

AIM:To determine whether bispectral index (BIS) monitoring is useful for propofol administration for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:Fifty-nine consecutive patients with a variety of reasons for ERCP who underwent the procedure at least twice between 1 July 2010 and 30 November 2010. This was a randomized cross-over study, in which each patient underwent ERCP twice, once with BIS monitoring and once with control monitoring. Whether BIS monitoring was done during the first or second ERCP procedure was random. Patients were intermittently administered a mixed regimen including midazolam, pethidine, and propofol by trained nurses. The nurse used a routine practice to monitor sedation using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale or the BIS monitoring. The total amount of midazolam and propofol used and serious side effects were compared between the BIS and control groups. RESULTS:The mean total propofol dose administered was 53.1 ± 32.2 mg in the BIS group and 54.9 ± 30.8 mg in the control group (P = 0.673). The individual propofol dose received per minute during the ERCP procedure was 2.90 ± 1.83 mg/min in the BIS group and 3.44 ± 2.04 mg in the control group (P = 0.103). The median value of the MOAA/S score during the maintenance phase of sedation was comparable for the two groups. The mean BIS values throughout the procedure (from insertion to removal of the endoscope) were 76.5 ± 8.7 for all 59 patients in using the BIS monitor. No significant differences in the frequency of < 80% oxygen saturation, hypotension (< 80 mmHg), or bradycardia (< 50 beats/min) were observed between the two study groups. Four cases of poor cooperation occurred, in which the procedure should be stopped to add the propofol dose. After adding the propofol, the procedure could be conducted successfully (one case in the BIS group, three cases in the control group). The endoscopist rated patient sedation as excellent for all patients in both groups. All patients in both groups rated their level of satisfaction as high (no discomfort). During the post-procedural follow-up in the recovery area, no cases of clinically significant hypoxic episodes were recorded in either group. No other postoperative side effects related to sedation were observed in either group. CONCLUSION:BIS monitoring trend to slighlty reduce the mean propofol dose. Nurse-administered propofol sedation under the supervision of a gastroenterologist may be considered an alternative under anesthesiologist.

Gastric dysplasia may be an independent risk factor of an advanced colorectal neoplasm

AIM: To evaluate the relationship between gastric dysplasia and Helicobacter pylori (H pylori) and the occurrence of colorectal adenoma, and to defi ne the necessity for colonoscopy in patients with gastric dysplasia or H pylori infection.METHODS: From May 2005 to February 2008, 133 patients with established gastric dysplasia by gastroduo-denoscopy (EGD) were additionally investigated by colonoscopy. The authors compared results with those of 213 subjects who underwent both EGD and colonoscopy during the same period at the author’s Health Promotion Center as a control group. H pylori infection was evaluated in both the gastric dysplasia and control groups.RESULTS: The mean age of all 346 study subjects was 54.1 ± 10.5 years, and there were 258 (73%) men and 87 (27%) women. No signif icant difference was found between the H pylori positive and negative subjects in terms of the prevalence of colorectal adenoma and advanced colorectal adenoma (P = 0.261). Patients with gastric dysplasia showed no elevated risk of colorectal adenoma (OR = 0.910, 95% CI: 0.587-1.411, P = 0.738), but had a signif icantly higher risk of having advanced colorectal adenoma (OR = 3.382, 95% CI: 1.700-6.342, P = 0.000).CONCLUSION: The study emphasizes the need for colon surveillance in patients with gastric dysplasia, regardless of H pylori infection.

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction

AIM:To evaluate the safety and efficacy of partially covered self-expandable metallic stents(SEMSs)in benign pyloric obstruction.METHODS:We retrospectively analyzed data from 10consecutive patients with peptic ulcer-related pyloric obstructive symptoms(gastric outlet obstruction scoring system(GOOSS)score of 1)between March 2012and September 2013.The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center.We assessed the technical success,symptom improvement,and adverse events after stenting.RESULTS:Early symptoms were improved just 3 d after SEMS placement in all 10 patients.The GOOSS score of all patients improved from 1 to 3.There were no serious immediate adverse events.The overall rate of being symptom free was 90%at a median of 11mo of follow-up(range:4-43 mo).Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation.Among them,four patients had sustained symptom improvement after the SEMS procedure.During the follow-up period,migration of the SEMS was observed in two patients(20.0%),both of whom had previous endoscopic balloon dilatation before SEMS insertion.CONCLUSION:Despite the small number in this study,partially covered SEMSs showed a favorable and safe outcome in the treatment of na?ve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

A comparison of transanal excision and endoscopic resection for early rectal cancer

AIM:To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer.METHODS:Thirty-two patients with early rectal cancer were treated by transanal excision or endoscopic resection between May 1999 and December 2007.The patients were regularly re-examined by means of colonoscopy and abdominal computed tomography after resection of the early rectal cancer.Complications,length of hospital-stay,disease recurrence and follow up outcomes were assessed.RESULTS:Sixteen patients were treated by endoscopic resection and 16 patients were treated by transanal excision.No significant differences were present in the baseline characteristics.The rate of complete resection in the endoscopic resection group was 93.8%,compared to 87.5% in the transanal excision group(P=0.544).The mean length of hospital-stay in the endoscopic resection group was 2.7 ± 1.1 d,compared to 8.9 ± 2.7 d in the transanal excision group(P=0.001).The median follow up was 15.0 mo(range 6-99).During the follow up period,there was no case of recurrent disease in either group.CONCLUSION:Endoscopic resection was a safe and effective method for the treatment of early rectal cancers and its outcomes were comparable to those of transanal excision procedures.

Traumatic pancreatic ductal injury treated by endoscopic stenting in a 9-year-old boy:A case report

BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Traumatic pancreatic injuries often result in delayed presentation and treatment,leading to high morbidity and mortality.The management of children with traumatic main pancreatic duct injuries is still under debate.CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.