Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol

BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversal agents.More needs to be reported on rates of reversal across different outpatient settings.Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center(APC)for their procedure.Here,we report data on outpatient sedation reversal rates for endoscopy performed at an inhospital APC vs at a free-standing ambulatory endoscopy digestive health center(AEC-DHC)following risk stratification with a triage tool.AIM To observe the effect of risk stratification using a triage tool on patient outcomes,primarily sedation reversal events.METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019.Procedures were stratified to their respective sites using a triage tool.We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded.Demographics and characteristics recorded include patient age,gender,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,procedure type,and reason for sedation reversal.RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period.Of these,17 patients at AEC-DHC and 9 at the APC underwent sedation reversals(0.017%vs 0.04%;P=0.06).Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age(53.5±21 vs 60.4±17.42 years;P=0.23),ASA class(1.66±0.48 vs 2.22±0.83;P=0.20),BMI(27.7±6.7 kg/m^(2) vs 23.7±4.03 kg/m^(2);P=0.06),and female gender(64.7%vs 22%;P=0.04).The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam(5.9±1.7 mg vs 8.9±3.5 mg;P=0.01),fentanyl(147.1±49.9μg vs 188.9±74.1μg;P=0.10),flumazenil(0.3±0.18μg vs 0.17±0.17μg;P=0.13)and naloxone(0.32±0.10 mg vs 0.28±0.12 mg;P=0.35).Procedures at AEC-DHC requiring sedation reversal included colonoscopies(n=6),esophagogastroduodenoscopy(EGD)(n=9)and EGD/colonoscopies(n=2),whereas APC procedures included EGDs(n=2),EGD with gastrostomy tube placement(n=1),endoscopic retrograde cholangiopancreatography(n=2)and endoscopic ultrasound's(n=4).The indications for sedation reversal at AEC-DHC included hypoxia(n=13;76%),excessive somnolence(n=3;18%),and hypotension(n=1;6%),whereas,at APC,these included hypoxia(n=7;78%)and hypotension(n=2;22%).No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site.CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures.Using a triage tool for risk stratification,low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.

Pregnancy and inflammatory bowel diseases: Current perspectives, risks and patient management

Inflammatory bowel diseases(IBD) are chronic idiopathic inflammatory conditions characterized by relapsing and remitting episodes of inflammation which can affect several different regions of the gastrointestinal tract, but also shows extra-intestinal manifestations. IBD is most frequently diagnosed during peak female reproductive years, with 25% of women with IBD conceiving after their diagnosis. While IBD therapy has improved dramatically with enhanced surveillance and more abundant and powerful treatment options, IBD disease can have important effects on pregnancy and presents several challenges for maintaining optimal outcomes for mothers with IBD and the developing fetus/neonate. Women with IBD, the medical team treating them(both gastroenterologists and obstetricians/gynecologists) must often make highly complicated choices regarding conception, pregnancy, and post-natal care(particularly breastfeeding) related to their choice of treatment options at different phases of pregnancy as well as post-partum. This current review discusses current concerns and recommendations for pregnancy duringIBD and is intended for gastroenterologists, general practitioners and IBD patients intending to become,(or already) pregnant, and their families. We have addressed patterns of IBD inheritance, effects of IBD on fertility and conception(in both men and women), the effects of IBD disease activity on maintenance of pregnancy and outcomes, risks of diagnostic procedures during pregnancy and potential risks and complications associated with different classes of IBD therapeutics. We also have evaluated the clinical experience using "top-down" care with biologics, which is currently the standard care at our institution. Post-partum care and breastfeeding recommendations are also addressed.

Accelerated infliximab infusions for inflammatory bowel disease improve effectiveness

AIM:To study the safety and effectiveness associated with accelerated infliximab infusion protocols in patients with inflammatory bowel disease(IBD).METHODS:Original protocols and infusion rates were developed for the administration of infliximab over 90-min and 60-min.Then the IBD patients on stable maintenance infliximab therapy were offered accelerated infusions.To be eligible for the study,patients needed a minimum of four prior infusions.An initial infusion of 90-min was given to each patient;those tolerating the accelerated infusion were transitioned to a 60-min infusion protocol at their next and all subsequent visits.Any patient having significant infusion reactions would be reverted to the standard 120-min protocol.A change in a patient's dose mandated a single 120-min infusion before accelerated infusions could be administered again.RESULTS:The University of Virginia Medical Center's Institutional Review Board approved this study.Fifty IBD patients treated with infliximab 5mg/kg,7.5mg/kg and 10mg/kg were offered accelerated infusions.Forty-six patients consented to participate in the study.Nineteen(41.3%) were female,five(10.9%) were African American and nine(19.6%) had ulcerative colitis.The mean age was 42.6 years old.Patients under age 18 were excluded.Ten patients used immunosuppressive drugs concurrently out of which six were taking azathioprine,three were taking 6-mercaptopurine and one was taking methotrexate.One of the 46 study patients used corticosteroid therapy for his IBD.Seventeen of the patients used prophylactic medications prior to receiving infusions;six patients received corticosteroids as pre-medication.Four patients had a history of distant transfusion reactions to infliximab.These reactions included shortness of breath,chest tightness,flushing,pruritus and urticaria.These patients all took prophylactic medications before receiving infusions.46 patients(27 males and 19 females) received a total of fifty 90-min infusions and ninety-three 60-min infusions.No infusion reactions were reported.There were no adverse events,including drug-related infections.None of the patients developed cancer of any type during the study timeframe.Total cost savings for administration of the both 90-min and 60-min accelerated infusions compared to standard 120-min infusions was estimated to be $53 632($116 965 vs $63 333,P=0.001).One hundred and eighteen hours were saved in the administration of the accelerated infusions(17 160 min vs 10 080 min,P=0.001).In the study population,overweight females [body mass index(BMI)>25.00kg/m2] were found to have statistically higher BMIs than overweight males(mean BMI 35.07±2.66kg/m2 vs 30.08±0.99kg/m2,P=0.05),finding which is of significance since obesity was described as being one of the risk factors for Crohn's disease.CONCLUSION:We are the first US group to report substantial cost savings,increased safety and patient satisfaction associated with accelerated infliximab infusion.

Adenosine:An immune modulator of inflammatory bowel diseases

Inflammatory bowel disease(IBD)is a common and lifelong disabling gastrointestinal disease.Emerging treatments are being developed to target inflammatory cytokines which initiate and perpetuate the immune response.Adenosine is an important modulator of inflammation and its anti-inflammatory effects have been well established in humans as well as in animal models.High extracellular adenosine suppresses and resolves chronic inflammation in IBD models.High extracellular adenosine levels could be achieved by enhanced adenosine absorption and increased de novo synthesis.Increased adenosine concentration leads to activation of the A2a receptor on the cell surface of immune and epithelial cells that would be a potential therapeutic target for chronic intestinal inflammation. Adenosine is transported via concentrative nucleoside transporter and equilibrative nucleoside transporter transporters that are localized in apical and basolateral membranes of intestinal epithelial cells,respectively. Increased extracellular adenosine levels activate the A2a receptor,which would reduce cytokines responsible for chronic inflammation.

Role of endoscopic ultrasound in esophageal cancer

Esophageal cancer(ECA)affects 1 in 125 men and 1 in 417 for women and accounts for 2.6%of all cancer related deaths in the United States.The associated survival rate depends on the stage of the cancer at the time of diagnosis,making adequate work up and staging imperative.The 5-year survival rate for localized disease is 46.4%,regional disease is 25.6%,and distant/metastatic disease is 5.2%.Additionally,treatment is stage-dependent,making staging all that much important.For nonmetastatic transmural tumors(T3)and/or those that have locoregional lymph node involvement(N),neoadjuvant therapy is recommended.Conversely,for those who have earlier tumors,upfront surgical resection is reasonable.While positron emission tomography/computed tomography and other cross sectional imaging modalities are exceptional for detecting distant disease,they are inaccurate in staging locoregional disease.Endoscopic ultrasound(EUS)has played a key role in the locoregional(T and N)staging of newly diagnosed ECA and has an evolving role in restaging after neoadjuvant therapy.There is even data to support that the use of EUS facilitates proper triaging of patients and may ultimately save money by avoiding unnecessary or futile treatment.This manuscript will review the current role of EUS on staging and restaging of ECA.

推进式食管-胃-十二指肠镜的病灶检出率依赖于隐匿性胃肠道出血的类型

Background and study aims: Many lesions found during push enteroscopy to evaluate obscure gastrointestinal bleeding are within the reach of standard endoscopes. The aim of this study was to determine whether the rate of proximal lesions varies in relation to the type of obscure bleeding that is present. Patients and methods: A retrospective review of consecutive push enteroscopies carried out for obscure gastrointestinal bleeding between July 1996 and July 2000 was conducted. The patients were categorized into three groups: those with recurrent obscure/overt gastrointestinal bleeding; those with persistent obscure/overt gastrointestinal bleeding; and those with obscure/ occult gastrointestinal bleeding. Results: A total of 63 patients (24 men, 39 women; mean age 69.8) were included. Push enteroscopy examinations were conducted for recurrent obscure/overt bleeding in 32 patients; for persistent obscure/overt bleeding in 12 patients; and for obscure/occult bleeding in 19 patients. The overall diagnostic yield of push enteroscopy was 47% (15 of 32) in the group with recurrent obscure/overt bleeding; 66% (eight of 12) in the group with persistent obscure/overt bleeding; and 63% (12 of 19) in the group with obscure/occult bleeding. However, when lesions within the reach of standard esophagogastroduodenoscopy (EGD)were excluded, the yield of push enteroscopy was slightly higher in the group with recurrent obscure/overt bleeding (41% ) than in the groups with persistent obscure/overt bleeding (33% ) and obscure/ occult bleeding (26% ). There were fewer lesions within the reach of EGD in the group with recurrent obscure/overt bleeding than in the groups with persistent obscure/overt bleeding (6% vs. 33% ; P < 0.05) or obscure/occult bleeding (6% vs. 37% ; P < 0.05). Conclusions: Patients undergoing push enteroscopy for recurrent obscure/overt bleeding were significantly less likely to have lesions within the reach of EGD than patients with persistent obscure/overt bleeding or obscure/occult bleed-ing. Patients in the latter two groups would be able to undergo a repeat EGD examination before more intense evaluation with push enteroscopy or capsule endoscopy.

怀孕期进行ERCP的安全性和有效性

Background Choledocholithiasis during pregnancy increases the risk of morbidit y and mortality for both fetus and mother because of cholangitis and pancreatiti s. ERCP has been advocated as safe and effective in pregnant women, but fetal ra diation exposure is not routinely monitored. The aim of this study was to record fetal exposure to ionizing radiation during ERCP and to assess outcome. Methods Seventeen ERCPs were performed in pregnant women between January 1995 and Augus t 2003. Techniques to minimize fluoroscopy were used, and fluoroscopy times were recorded. Thermoluminescent dosimeters affixed to the skin of the mother were u sed to estimate fetal radiation exposure. Observations Mean gestational age was 18.6 (8.9) weeks (range 5-33 weeks). Mean fluoroscopy time was 14 (13) seconds (range 1-48 seconds). Estimated fetal radiation exposure was 40 (46) mrad (rang e 1-180 mrad).There was a correlation between fluoroscopy time and radiation ex posure, but there was a wide range of radiation exposure for individual fluorosc opy times. Complications included postsphincterotomy bleeding in one patient (co ntrolled by hemoclip placement) and post-ERCP pancreatitis in one patient that necessitated 3 days of hospitalization. Two women developed third-trimester pre eclampsia, and labor was induced in both.Thirteen of the 15 patients who deliver ed were contacted and they confirmed that their child was in good health. Conclu sions ERCP with modified techniques is safe during pregnancy.Dosimetry should be routinely recorded.

介入超声内镜引导的胆管造影:一项新技术评估

Background: Interventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful. Objective: We reviewed our experience and technique used for this procedure. Design: Over a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC. Setting: Tertiary care center offering ERCP and interventional EUS. Patients: Twenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC. Intervention: EUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished. Main Outcome Measurements: Efficacy and safety of IEUC for biliary decompression. Results: IEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding. Limitations: Single-center experience of 2 operators. Conclusions: IEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.

超声内镜引导的经肝穿刺胆管造影术:6例病例报道

Background: This report describes a novel application of EUS guided cholangio graphy in which a transhepatic approach was used to alleviate perihilar and dist al biliary obstructions when this could not be accomplished at ERCP. Methods: EU S- guided transhepatic cholangiography was used to alleviate symptoms of biliar y obstruction in 6 patients. In 4 cases, after transgastric puncture of an intra hepatic branch of the obstructed bile duct with a 19- or a 22- gauge EUS need le, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement. Observations: EUS- guided transhepatic cholangiography was per formed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsucc essful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures. Conc lusions: EUS- guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.

Barrett’s esophagus: review of diagnosis and treatment

Barrett’s esophagus(BE)is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium.Endoscopy with systemic biopsy protocols plays a vital role in diagnosis.Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia.These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy.A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa,followed by long-term surveillance improves the outcomes of BE.Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy,radiofrequency ablation and cryotherapy.Debatable issues such as durability of response,recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further.Development of safer wide field resection techniques,which would effectively remove all BE and obviate the need for long-term surveillance,is another research goal.Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.

One man’s trash-another man’s treasure: fecal transplantation

Discovery of immune checkpoint inhibitors has revolutionized the field of oncology.Immune checkpoints play a key role in maintaining immune homeostasis and preventing autoimmunity.Under normal situation,immune responses are regulated by a balance between co-stimulatory and inhibitory signals referred to as"immune checkpoints".Activated T cells express multiple co-inhibitory receptors such as lymphocyte-activation gene 3(LAG-3),programmed cell death protein 1(PD-1)and cytotoxic T-lymphocyte-associated protein 4(CTLA-4)that are primary mediators of immune effector responses to self-proteins,chronic infections and tumor antigens.In tumors these immune checkpoints allow the tumor cells to dodge anti-tumor response(1).Checkpoint inhibitors(CPI)block these immune checkpoints allowing the immune system to attack tumor cells(2).Although the immune system has the inherent ability to distinguish self from non-self and thus typically mount an attack on the non-self-cancer cells;over-activation of the immune response can lead to serious adverse events collectively called immune-related adverse events(irAEs)(3).While activation of the immune system and development of irAEs has been associated with better outcomes for underlying cancer(4),the associated side effects increase morbidity and mortality in addition to having a negative impact on patient’s quality of life.irAEs associated with CPI therapy can have delayed manifestation and present after the CPI have been discontinued(5).