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Efficiency of Propofol Sedation Versus Conscious Sedation with Midazolam and Fentanyl in a Pediatric Endoscopy Unit
Abstracts
444 Percutaneous Endoscopic Suture Ligation (PESL): New Technique for Closure of Gastrocutaneous Fistula Manoj Shah, George Yanni, Sally Rajcevich, Finese Child Gastrostomy tube (GT) is now widely used in children as temporary or permanent access for gastrointestinal feedings. If GT is no longer required, then it is removed which usually results in a spontaneous closure of the gastrocutaneous fistula (GCF). However, in a minority of patients, GCF persists resulting in leakage of gastric contents causing excoriation of peristomal skin, cellulitis, pain, and malnutrition. At present, these patients require surgical resection/closure of GCF. Recently, we have described some success in closure of GCF by endoscopic clipping. (1). Herein, we report a new endoscopic technique to close GCF by PESL. Methods: 4 patients with persistent GCF following GT removal and endoscopic clipping underwent PESL. (See figure) Patients were asked to eat small, solid meals for 2 days following the procedure to avoid gastric distension. Acid suppressive therapy was continued. Patients were contacted by telephone in 2 days and sutures were removed in 2 weeks. Results:
procedure. Results: Each procedure included 3 suture applications with a mean duration of 45 minutes. Improvement in symptoms such as heartburn, asthma, dysphagia and RQOLS was present and sustained at 12 month follow up in all but 1 patient. Total RQOLS (max 175) increased from median 97 (range 64-142) to a median 149 (range 104-175) (p!0.001) at 12 months. All ph and impedance parameters improved significantly in all but 1 patient. Median reflux index from 19.75% (range 7.6-23.7%) to 4.1% (range 0.7-11.2%) (p Z 0.001) at 12 months. 13/ 14 did not require any further use of PPIs. No complications were associated with the procedure. Conclusion: Endoscopic suturing is an effective and safe method to manage recurrent GERD after failed fundoplication in children, and demonstrates sustained efficacy at 12 months.
446 Efficiency of Propofol Sedation Versus Conscious Sedation with Midazolam and Fentanyl in a Pediatric Endoscopy Unit Jenifer Lightdale, Clarissa Valim, Adrienne Newburg, Steven Zgleszewski, Kate Donovan, Lisa Heard, Victor Fox
Conclusions: 1) PESL is a feasible technique in achieving closure of GCF. 2) This PESL method may need to be modified by using pledgets to prevent sutures from eroding.
445 Endoscopic Suturing for Treatment of Recurrent Gastroesophageal Reflux in Pediatric Patients with Failed Nissen Fundoplications Eduardo Ibarguen-Secchia Introduction: The frequent failure of surgical treatment for gastroesophageal reflux (GERD) is a growing concern among adult and pediatric gastroenterologists. This has led to the use of newer techniques such as endoscopic suturing, the Stretta procedure and the injection of polymers (Enteryx) into the lower esophageal sphincter as aletrnative methods to control GERD. The failure rate of Nissen fundoplications in children has been reported as high as 60 to 75 percent, even as early as 2 months after surgery. Many of these children will develop the same problems that led to a fundoplication. These include a variety of symptoms including aspiration, severe esophagitis, dysphagia or strictures. Doing a second fundoplication is usually even less effective than the first. So a different approach was considered, using endoscopic suturing (Wilson-Cook device) to reinforce the existing Nissen. Methods: 14 pediatric patients ages 6 to 14 years (mean 9 years) with failed fundoplications underwent endoscopic suturing. All patients had previously had a Nissen fundoplication. Patients were selected because of recurrence of their original symptoms following the fundoplication and failure to respond to PPIs. Patients underwent endoscopy, upper gastrointestinal series, 24 hour esophageal pH with impedance study, and completed a reflux quality of life score (RQOLS) before endoscopic suturing, as well as at 6 and 12 months after the
AB92 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Propofol has an ultra-short onset of action and short plasma half-life. Compared with standard conscious sedation (CS) regimens, propofol has been credited with minimizing times to sedation, speeding times to recovery and decreasing total times for GI procedures. Aim: To formally compare the efficiency of propofol sedation with that of midazolam and fentanyl CS in a pediatric endoscopy unit. Methods: For quality improvement purposes, we prospectively collected the following times for all patients undergoing anesthesiologist-administered propofol (bolus1-2 m/kg followed by 300-350 m/kg/h continuous infusion) from 5/5-9/9/2004 in the Endoscopy Unit at Children’s Hospital Boston: Time until sedated (time sedation started to scope in); procedure time (time scope in to scope out); recovery time (time scope out to hospital discharge); and total time (time entered procedure room to hospital discharge). Comparison was made to patients who received endoscopist-administered CS with midazolam (.05-.3 mg/kg IV, max dose 15 mg) and fentanyl (1-5 m/kg, max dose 250 m) from 12/9/03-11/16/04. Results: Times from 97 patients (52 male; median age 14 y (6m-20 y)) undergoing propofol were compared with those of 163 (89 male; median age 13y (6 m-19 y)) receiving CS. 12 staff endoscopists performed procedures in both groups; 6 staff anesthesiologists administered propofol. 36% of propofol (vs. 0 CS) patients received endotracheal intubation. CS cases disproportionately included EGDs (80% vs 46%, p!.0001), and patients classified as ASA I (86% vs. 46%, p!.001). ASA was not associated with propofol sedation times. Intubation prolonged propofol times (p!.01), but adjusting for it did not change comparison results. Procedure times were not different between groups. Propofol patients had shorter times until sedated, longer recovery times and comparable total times overall. Conclusions: Our results suggest anesthesiologist-administered propofol sedation may not be more efficient than endoscopist-administered CS in our endoscopy unit.
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444 Percutaneous Endoscopic Suture Ligation (PESL): New Technique for Closure of Gastrocutaneous Fistula Manoj Shah, George Yanni, Sally Rajcevich, Finese Child Gastrostomy tube (GT) is now widely used in children as temporary or permanent access for gastrointestinal feedings. If GT is no longer required, then it is removed which usually results in a spontaneous closure of the gastrocutaneous fistula (GCF). However, in a minority of patients, GCF persists resulting in leakage of gastric contents causing excoriation of peristomal skin, cellulitis, pain, and malnutrition. At present, these patients require surgical resection/closure of GCF. Recently, we have described some success in closure of GCF by endoscopic clipping. (1). Herein, we report a new endoscopic technique to close GCF by PESL. Methods: 4 patients with persistent GCF following GT removal and endoscopic clipping underwent PESL. (See figure) Patients were asked to eat small, solid meals for 2 days following the procedure to avoid gastric distension. Acid suppressive therapy was continued. Patients were contacted by telephone in 2 days and sutures were removed in 2 weeks. Results:
procedure. Results: Each procedure included 3 suture applications with a mean duration of 45 minutes. Improvement in symptoms such as heartburn, asthma, dysphagia and RQOLS was present and sustained at 12 month follow up in all but 1 patient. Total RQOLS (max 175) increased from median 97 (range 64-142) to a median 149 (range 104-175) (p!0.001) at 12 months. All ph and impedance parameters improved significantly in all but 1 patient. Median reflux index from 19.75% (range 7.6-23.7%) to 4.1% (range 0.7-11.2%) (p Z 0.001) at 12 months. 13/ 14 did not require any further use of PPIs. No complications were associated with the procedure. Conclusion: Endoscopic suturing is an effective and safe method to manage recurrent GERD after failed fundoplication in children, and demonstrates sustained efficacy at 12 months.
446 Efficiency of Propofol Sedation Versus Conscious Sedation with Midazolam and Fentanyl in a Pediatric Endoscopy Unit Jenifer Lightdale, Clarissa Valim, Adrienne Newburg, Steven Zgleszewski, Kate Donovan, Lisa Heard, Victor Fox
Conclusions: 1) PESL is a feasible technique in achieving closure of GCF. 2) This PESL method may need to be modified by using pledgets to prevent sutures from eroding.
445 Endoscopic Suturing for Treatment of Recurrent Gastroesophageal Reflux in Pediatric Patients with Failed Nissen Fundoplications Eduardo Ibarguen-Secchia Introduction: The frequent failure of surgical treatment for gastroesophageal reflux (GERD) is a growing concern among adult and pediatric gastroenterologists. This has led to the use of newer techniques such as endoscopic suturing, the Stretta procedure and the injection of polymers (Enteryx) into the lower esophageal sphincter as aletrnative methods to control GERD. The failure rate of Nissen fundoplications in children has been reported as high as 60 to 75 percent, even as early as 2 months after surgery. Many of these children will develop the same problems that led to a fundoplication. These include a variety of symptoms including aspiration, severe esophagitis, dysphagia or strictures. Doing a second fundoplication is usually even less effective than the first. So a different approach was considered, using endoscopic suturing (Wilson-Cook device) to reinforce the existing Nissen. Methods: 14 pediatric patients ages 6 to 14 years (mean 9 years) with failed fundoplications underwent endoscopic suturing. All patients had previously had a Nissen fundoplication. Patients were selected because of recurrence of their original symptoms following the fundoplication and failure to respond to PPIs. Patients underwent endoscopy, upper gastrointestinal series, 24 hour esophageal pH with impedance study, and completed a reflux quality of life score (RQOLS) before endoscopic suturing, as well as at 6 and 12 months after the
AB92 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Propofol has an ultra-short onset of action and short plasma half-life. Compared with standard conscious sedation (CS) regimens, propofol has been credited with minimizing times to sedation, speeding times to recovery and decreasing total times for GI procedures. Aim: To formally compare the efficiency of propofol sedation with that of midazolam and fentanyl CS in a pediatric endoscopy unit. Methods: For quality improvement purposes, we prospectively collected the following times for all patients undergoing anesthesiologist-administered propofol (bolus1-2 m/kg followed by 300-350 m/kg/h continuous infusion) from 5/5-9/9/2004 in the Endoscopy Unit at Children’s Hospital Boston: Time until sedated (time sedation started to scope in); procedure time (time scope in to scope out); recovery time (time scope out to hospital discharge); and total time (time entered procedure room to hospital discharge). Comparison was made to patients who received endoscopist-administered CS with midazolam (.05-.3 mg/kg IV, max dose 15 mg) and fentanyl (1-5 m/kg, max dose 250 m) from 12/9/03-11/16/04. Results: Times from 97 patients (52 male; median age 14 y (6m-20 y)) undergoing propofol were compared with those of 163 (89 male; median age 13y (6 m-19 y)) receiving CS. 12 staff endoscopists performed procedures in both groups; 6 staff anesthesiologists administered propofol. 36% of propofol (vs. 0 CS) patients received endotracheal intubation. CS cases disproportionately included EGDs (80% vs 46%, p!.0001), and patients classified as ASA I (86% vs. 46%, p!.001). ASA was not associated with propofol sedation times. Intubation prolonged propofol times (p!.01), but adjusting for it did not change comparison results. Procedure times were not different between groups. Propofol patients had shorter times until sedated, longer recovery times and comparable total times overall. Conclusions: Our results suggest anesthesiologist-administered propofol sedation may not be more efficient than endoscopist-administered CS in our endoscopy unit.
www.mosby.com/gie