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Leung CM, Hui RWH. Comparing general anaesthesia versus sedation for endoscopic submucosal dissection: results from a systematic review and meta-analysis. Anaesthesiol Intensive Ther 2023; 55:9-17. [PMID: 37306267 PMCID: PMC10156556 DOI: 10.5114/ait.2023.125416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/22/2022] [Indexed: 09/08/2024] Open
Abstract
Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure for management of gastrointestinal tumours. ESD is usually performed under sedation. However, the use of general anaesthesia (GA) has been hypothesised to improve ESD outcomes. We performed a systematic review and meta-analysis to compare GA against sedation in ESD. A systematic literature search was performed on Cochrane Library, EMBASE and MEDLINE using the terms "General Anaesthesia", "Sedation" and "Endoscopic submucosal dissection". Original articles comparing GA versus sedation in ESD were included. The risk of bias and level of evidence were assessed by validated methods. This review is registered in PROSPERO (CRD42021275813). 176 articles were found in the initial literature search, and 7 articles (comprising 518 patients receiving GA and 495 receiving sedation) were included. Compared with sedation, GA was associated with higher en-bloc resection rates in oesophageal ESD (RR 1.05; 95% CI: 1.00-1.10; I 2 = 65%; P = 0.05). GA patients also trended towards lower rates of gastrointestinal perforation in all ESD procedures (RR 0.62; 95% CI: 0.21-1.82; I 2 = 52%; P = 0.06). Rates of intra- procedural desaturation and post-procedural aspiration pneumonia were lower in GA patients than in patients under sedation. The included studies had a moderate to high risk of bias, and the overall level of evidence was low. GA appears safe and feasible for ESD, yet high-quality trials will be required before GA can be regularly implemented for ESD.
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Affiliation(s)
- Choy-May Leung
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Hong Kong
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Imamura K, Machii M, Yao K, Sou S, Nagahama T, Yao T, Kanemitsu T, Miyaoka M, Ohtsu K, Ueki T. Measurement of intragastric pressure: an objective method to ascertain whether gastric wall extension is sufficient for assessment of the non-extension sign. Endosc Int Open 2021; 9:E530-E536. [PMID: 33816773 PMCID: PMC7969131 DOI: 10.1055/a-1352-2761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/09/2020] [Indexed: 11/02/2022] Open
Abstract
Background and study aims The optimal intragastric pressure (IP) for strong gastric wall extension is unclear. We aimed to develop an accurate method to measure IP using endoscopy and determine the pressure required for strong gastric wall extension. Methods An in vitro experiment using an endoscope with a rubber attached at its tip was conducted. The process of inserting the pressure measurement probe into the forceps channel was skipped, and the tube of the pressure measurement device was directly connected to the forceps channel. In vivo, the pressure in 51 consecutive patients at the time of strong gastric wall extension was measured. Strong extension of the gastric wall was defined as when the folds in the greater curvature were flattened as a result of sufficient extension of the gastric wall by insufflated air during upper gastrointestinal endoscopy. The IP at that time was measured. Results In vitr o , 20 mL of tap water was injected once into the forceps channel and then aspirated for 10 seconds. Pressure measurement after irrigation of the forceps channel as well as the measurement by inserting the probe procedure were accurately performed. In vivo, among the 51 included patients, the mean IP (range) was 14.7 mmHg (10-23). Strong extension of the gastric wall was obtained in 96.1 % of patients when the IP was 20 mmHg. Conclusions We developed an accurate method to measure IP using upper gastrointestinal endoscopy. Strong extension of the gastric wall was obtained in almost all patients when the IP was 20 mmHg.
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Affiliation(s)
- Kentaro Imamura
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Motoko Machii
- Department of Gastroenterology, Tobata Kyoritsu Hospital, Kitakyushu, Japan
| | - Kenshi Yao
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Suketo Sou
- Department of Gastroenterology, Tobata Kyoritsu Hospital, Kitakyushu, Japan
| | | | - Tsuneyoshi Yao
- Department of Gastroenterology, Sada Hospital, Fukuoka, Japan
| | - Takao Kanemitsu
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Masaki Miyaoka
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Kensei Ohtsu
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikusino, Japan
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Choi SI, Park JC. Commentary on "Efficacy of Endoscopic Submucosal Dissection of Esophageal Neoplasms under General Anesthesia". Clin Endosc 2019; 52:205-206. [PMID: 31117338 PMCID: PMC6547344 DOI: 10.5946/ce.2019.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Soo In Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Baniya R, Upadhaya S, Khan J, Subedi SK, Mohammed TS, Ganatra BK, Bachuwa G. Carbon Dioxide versus Air Insufflation in Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Endosc 2017; 50:464-472. [PMID: 28516756 PMCID: PMC5642065 DOI: 10.5946/ce.2016.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/26/2017] [Accepted: 03/29/2017] [Indexed: 12/20/2022] Open
Abstract
Background/Aims Endoscopic submucosal dissection (ESD) with air insufflation is commonly used for the staging and treatment of early gastric carcinoma. However, carbon dioxide (CO2) use has been shown to cause less post-procedural pain and fewer adverse events. The objective of this study was to compare the post-procedural pain and adverse events associated with CO2 and air insufflation in ESD. Methods A systematic search was conducted for randomized control trials (RCTs) comparing the two approaches in ESD. The Mantel-Haenszel method was used to analyze the data. The mean difference (MD) and odds ratio (OR) were used for continuous and categorical variables, respectively. Results Four RCTs with a total of 391 patients who underwent ESD were included in our meta-analysis. The difference in maximal post-procedural pain between the two groups was statistically significant (MD, -7.41; 95% confidence interval [CI], -13.6 – -1.21; p=0.020). However, no significant differences were found in the length of procedure, end-tidal CO2, rate of perforation, and postprocedural hemorrhage between the two groups. The incidence of overall adverse events was significantly lower in the CO2 group (OR, 0.51; CI, 0.32–0.84; p=0.007). Conclusions: CO2 insufflation in gastric ESD is associated with less post-operative pain and discomfort, and a lower risk of overall adverse events compared with air insufflation.
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Affiliation(s)
- Ramkaji Baniya
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Sunil Upadhaya
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Jahangir Khan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Suresh K Subedi
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Tabrez S Mohammed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Balvant K Ganatra
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
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Ishibashi C, Hayashida M, Sugasawa Y, Yamaguchi K, Tomita N, Kajiyama Y, Inada E. Effects of dexmedetomidine on hemodynamics and respiration in intubated, spontaneously breathing patients after endoscopic submucosal dissection for cervical esophageal or pharyngeal cancer. J Anesth 2016; 30:628-36. [PMID: 27125210 DOI: 10.1007/s00540-016-2175-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 04/17/2016] [Indexed: 01/28/2023]
Abstract
PURPOSE We evaluated the hemodynamic and respiratory effects of dexmedetomidine in intubated, spontaneously breathing patients after endoscopic submucosal dissection (ESD) for cervical esophageal or pharyngeal cancer. METHODS This retrospective study included 129 patients aged 66.5 ± 8.3 years, who underwent ESD under general anesthesia, and who were kept intubated overnight to prevent airway obstruction, receiving sedation with dexmedetomidine. Constant dexmedetomidine infusion at 0.51 ± 0.16 μg/kg/h was started intraoperatively (n = 109) or postoperatively (n = 20), following (n = 29) or not following (n = 100) loading doses, and continued until extubation. Hemodynamic and respiratory variables, and Richmond Agitation-Sedation Scale (RASS) score, were recorded. RESULTS Postoperatively, 129 patients remained intubated while breathing spontaneously for 16.4 ± 3.3 h, and 124 patients could be sedated solely with dexmedetomidine, whereas 5 required rescue sedatives. During infusion, blood pressure decreased progressively until 12 h, whereas heart rate decreased only at 3 h. Hemodynamic alterations during dexmedetomidine infusion greatly depended not only on its hemodynamic effects but also on baseline hemodynamics before anesthesia. No serious adverse effect was noted. CONCLUSION Dexmedetomidine in intubated, spontaneously breathing patients after ESD was safe and effective. Patient baseline hemodynamics could significantly affect hemodynamics during drug infusion. Without loading doses, plasma drug concentrations were expected to increase progressively. A progressive decrease in blood pressure and unchanged heart rate after an initial decrease suggested that hemodynamic effects of dexmedetomidine in our patients might differ from those reported in young volunteers, although further studies are required to elucidate these points.
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Affiliation(s)
- Chika Ishibashi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Yusuke Sugasawa
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan.
| | - Keisuke Yamaguchi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Natsumi Tomita
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiaki Kajiyama
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
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Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T, Hoshino S, Nimura S, Yamaura K, Yamashita Y. Efficacy and safety of endoscopic submucosal dissection under general anesthesia. World J Gastrointest Endosc 2016; 8:466-471. [PMID: 27433293 PMCID: PMC4937162 DOI: 10.4253/wjge.v8.i13.466] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) under general anesthesia.
METHODS: From January 2011 to July 2014, 206 consecutive patients had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum were enrolled in this retrospective study. The efficacy and safety of ESD under general anesthesia were assessed.
RESULTS: The en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required.
CONCLUSION: With the cooperation of an anesthesiologist, ESD under general anesthesia appears to be a useful method, decreasing the risk of complications.
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Eleftheriadis N, Inoue Η, Ikeda H, Onimaru M, Yoshida A, Maselli R, Santi G, Hamatani S, Kudo SE. Effective optical identification of type "0-IIb" early gastric cancer with narrow band imaging magnification endoscopy, successfully treated by endoscopic submucosal dissection. Ann Gastroenterol 2015; 28:72-80. [PMID: 25609014 PMCID: PMC4290007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 08/16/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is currently considered the minimal invasive endoscopic treatment for early gastric cancer. Most superficial gastric neoplastic lesions are depressed type "0-IIc" (70-80%), while totally flat, classified as type "0-IIb" early gastric cancer, is rarely reported (0.4%). The aim of the present study was to assess the efficacy of narrow band imaging (NBI) magnification endoscopy in identifying type "0-IIb" early gastric cancer and ESD treatment with curative intention. METHODS Twelve of 615 (2%) patients (10 males, median 72 years), treated by ESD at our center, were diagnosed as type "0-IIb" gastric cancer. Ten had exclusively type "0-IIb", while two had combined types "0-IIb+IIc" and "0-IIa+IIb" gastric cancer. Initial diagnosis was made during screening gastroscopy, while NBI magnification endoscopy combined with indigo-carmine chromoendoscopy were also used. RESULTS White light endoscopy showed only superficial redness. One patient with signet-ring carcinoma showed whitish appearance. Indigo-carmine chromoendoscopy showed better visualization, while NBI magnification endoscopy revealed abnormal mucosal microsurface and microvascular findings which enabled border marking. ESD with curative intention was completed without complications. Histological examination showed complete (R0) resection, in 10 patients (83%). One patient with positive margins received additional surgery (8%). Mean procedure time was 149 (range 60-190) min. One to six years post-ESD all patients remain alive. CONCLUSIONS ESD is considered a safe and effective curative treatment for type "0-IIb" gastric cancer, resulting in long-term disease-free survival. NBI magnification endoscopy is effective for accurate optical identification and border marking of type "0-IIb" early gastric cancer.
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Affiliation(s)
- Nikolas Eleftheriadis
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Ηaruhiro Inoue
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Haruo Ikeda
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Manabu Onimaru
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Akira Yoshida
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Roberta Maselli
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Grace Santi
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Shigeharu Hamatani
- Department of Pathology (Shigeharu Hamatani), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
| | - Shin-ei Kudo
- Digestive Disease Center (Nikolas Eleftheriadis, Ηaruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Roberta Maselli, Grace Santi, Shin-ei Kudo), Showa University Northern Yokohama Hospital, Tsuzuki-ku, Yokohama, Japan
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Endoscopic submucosal dissection to treat ileal high-grade dysplasia after ileoanal anastomosis for familial adenomatous polyposis: report of a case. Clin J Gastroenterol 2014; 7:481-3. [PMID: 25491906 DOI: 10.1007/s12328-014-0533-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/02/2014] [Indexed: 10/24/2022]
Abstract
Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis patients, based on the premise that the technique yields good functional results and reduces colorectal cancer risk. However, several adenomas may develop in the pouch mucosa in later years, and even cancer (at the anastomosis or in the pouch mucosa) has been reported. Endoscopic submucosal dissection (ESD) would then be indicated, even if severe fibrosis extended into the submucosal layer. Endoscopic resection of an ileal tumor from the thin wall of the ileum carries a high-risk of perforation. Our present case demonstrates the successful use of ESD to treat an ileal neoplasm, a technically difficult lesion with a high-risk of complications.
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Mori H, Takao H, Kobara H, Nishiyama N, Fujihara S, Matsunaga T, Ayaki M, Masaki T. Precise tumor size measurement under constant pressure by novel real-time micro-electro-mechanical-system hood for proper treatment (with videos). Surg Endosc 2014; 29:212-9. [PMID: 24993169 PMCID: PMC4293473 DOI: 10.1007/s00464-014-3642-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 05/16/2014] [Indexed: 02/07/2023]
Abstract
Background Tumor size determination is subject to the measurement method used by endoscopists and is especially dependent on the air quantity. As the intraluminal pressure must be measured objectively to obtain an accurate tumor size measurement, insufflation can affect the results. Thus, we examined the utility of a micro-electro-mechanical-system (MEMS) pressure sensor hood. Methods Twenty consecutive air insufflation/deflation tests were performed in vivo using a dog’s stomach. Correlations between the actual pressure measured and the signal strength of the MEMS hood were measured. We marked 2 points 20 mm on the antrum and another 3 points, with insufflation corresponding to the maximum stable distance of two markings. We performed five insufflation/deflation tests to obtain the relationship between pressure and distances to accurately measure the distance under constant pressure. Results In the air insufflation/deflation test performed 20 consecutive times, the MEMS hood signal strength (V) and the pressure measurement sensor values (mmHg) showed good correlation. There was good correlation between intraluminal pressures of 2.5–40 mmHg and the two marking distances on the antrum (correlation coefficient 0.952) (P < 0.05). However, once the intraluminal pressure reached a certain level (40 mmHg), expansion of the two marking distances ceased. The same measurements were conducted on the greater curvatures of the lower body and middle body and on the lesser curvature of the lower body. Conclusions Correct tumor size measurements using a MEMS hood enable a more accurate diagnosis, which can be used to develop suitable treatment strategies. Electronic supplementary material The online version of this article (doi:10.1007/s00464-014-3642-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hirohito Mori
- Department of Gastroenterology and Neurology, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan,
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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