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Sedation for upper gastrointestinal endoscopy: time for reappraisal?
ing, and participating in outcome analysis studies by both government and private agencies. 4. Fund, support, and design endoscopic research utilizing broad membership involvement where possible. 5. Strengthen A/S/G/E leadership in the presentation and evaluation of new endoscopic technology and procedures. 6. Significantly improve two-way communication between the A/S/G/E and its members. 7. Maintain A/S/G/E educational leadership through new and innovative educational programs and methods. 8. Increase membership volunteerism and participation in the Society objectives. 9. Establish programs for postgraduate hands-on training in endoscopic procedures for A/S/G/E members. 10. Strengthen the A/S/G/E programs for education of the public concerning the benefits of endoscopy in the diagnosis and treatment of gastrointestinal disease. 11. Continue to influence and improve the certification process as it applies to endoscopic procedures. 12. Establish a long-term financial plan to support these strategic planning objectives. These principles and objectives were submitted to the A/ S/G/E Governing Board at the 1990 annual meeting and were adopted as the framework for the course of the A/S/ G/E will take as it begins its second 50 years. Recognizing that the success of such efforts require a committed constituency, the projects have been referred to the appropriate committees and an implementor has been selected for each. The committee and the implementor (usually the committee chair) have been directed to develop action plans for each of the projects. Their progress will be reported from time to time in the A/S/G/E newsletter and other mailings. With these deliberations, projects, and their action plans, it would appear that the A/S/G/E is well launched into its second half century. The remarkable strength and adaptability shown during the first 50 years should stand the organization well as future changes in health care, and its delivery, unfold.
Letters to the Ed itor New computer simulation study group formed To the Editor: The Computer Simulation Study Group was formed during the Digestive Disease Week Meeting in San Antonio, Texas. The goals of this group will include the development of equipment for computer-assisted teaching of endoscopic technique, and the assessment of devices concerning their potential for developing skills in gastrointestinal endoscopy. The long-term goals will encompass incorporation and evaluation of the motor and cognitive skills required for the safe and successful performance of endoscopy. The founding members are: John Baillie, Durham, N.C., Marc Beer-Gabel, Reims, France, Thomas Fabry, N.Y., N.Y., Duncan Gillies, London, U.K., Angelo Haritsis, LonVOLUME 36, NO.4, 1990
don, U.K., Mark Noar, Towson, Md., Jerome D. Waye, N.Y., and Christopher B. Williams, London, U.K. This study group will be a vehicle for communication of ideas and sharing of knowledge. Membership is open to anyone who has demonstrated commitment to this field by having developed a working computer system for teaching endoscopy. Meetings will be held at sites of gastrointestinal meetings. The next meeting will be held in Sydney, Australia, in August 1990. Christopher J. Barde, MD Department of Medicine (111) Dayton Veterans Administration Medical Center Dayton, Ohio
Sedation for upper gastrointestinal endoscopy: time for reappraisal? To the Editor: We read with interest the recent report by AI-Atrakchi,' who successfully performed 2000 upper gastrointestinal endoscopies without sedation. We would like to draw attention to a similar study, which we published in 1986. 2 In this study we used a preliminary test of pharyngeal sensitivity (the finger-throat test) and were able to predict (positive predictive value, 1.00; negative predictive value, 0.93) patient tolerance to endoscopic examination. Our paper 2 has been favorably criticized by Maratka. 3 Since the publication of our study,2 we have performed more than 3000 upper gastrointestinal endoscopies without sedation in most of our in-patients and out-patients, predicting their tolerance of the procedure by the finger-throat test. During this period (1986 to 1988), five trainees in gastroenterology performed a total of 1128 consecutive successful examinations (median, 125; range, 76 to 575) using forward-viewing endoscopes (Olympus Q or GIF-IT20). Sedation had to be used (intravenous diazepam) in 2.6 to 13.8% (median, 6.4%) of patients which is similar to the range of 1.6 to 12.0% reported by AI-Atrakchi' and Ladas and Raptis. 2 Only seven (0.6%) examinations failed. The toleration of the procedure, as it was reported by each of the five trainees, was excellent or satisfactory in most patients and poor in only 1.8 to 12.5% (median, 4.6%), which is also comparable to 7% and 1.8% reported by us 2 and AI-Atrakchi,' respectively. In addition, during the same period (1986 to 1988), using the finger-throat test, we were able to perform ERCP without (or with light) sedation (2.5 to 5 mg of intravenous diazepam) in a substantial number of patients (100 and 334, respectively), i.e., 16.1 and 53.7%, respectively, of a total of 622 ERCPs. We have even performed a small number of sphincterotomies without any sedation. We think it is time for reappraisal of systematically using sedation for upper gastrointestinal endoscopy. Since not all patients can tolerate peroral endoscopy without sedation, we recommend the use of a test to predict patient tolerance. Spiros D. Ladas, Constantine Giorgiotis, Prokopis Pipis, Christos Papaioannou,
MD MD MD MD 417
Pericles Tassios, MD Evangelia Karra, MD Sotos A. Raptis, MD Gastroenterology Unit Second Department of Internal Medicine-Propaedeutic Evangelismos Hospital Athens, Greece
delayed hemorrhage after hot biopsy treatment of diminutive polyps that is the emphasis of this communication as well as that of Quigley et al.' They raise significant questions regarding this technique, and the possible short-circuit effect resulting from mucosal contact of the metal shaft with the mucosa. I have no reason to believe that to be a contributing factor in this case. However, the need for caution and reserve on the power settings when working in the cecum needs to be underscored.
REFERENCES 1. Al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989;35:79-81. 2. Ladas SD, Raptis SA. Selection of patients for upper gastrointestinal endoscopy without sedation. The finger-throat test. Ital J GastroenteroI1986;18:162-5. 3. Maratka Z. Selection of patients for upper gastrointestinal endoscopy without sedation. The finger-throat test. Gastrointest Endosc 1987;33:405-6.
Delayed hemorrhage following "hot biopsy" of a diminutive colonic polyp To the Editor: I read with great interest the recent report by Quigley et al.' describing the delayed onset of massive hemorrhage following polyp ablation using the hot biopsy technique in the cecum. A similar complication was recently encountered which underscores the concerns they have raised. A 59-year-old man had a colonoscopic evaluation elsewhere, during which a cecal diminutive polyp was encountered and treated by hot biopsy ablation. Biopsy ofthe lesion showed hyperplastic tissue. One week later, while visiting this area ofthe country, the patient presented with the acute onset of massive hematochezia and hypotension. The physical examination demonstrated no evidence of organomegally or stigmata of chronic liver disease. All clotting parameters were within normal limits. A bleeding scan utilizing technetium-labeled red blood cells demonstrated immediate localization in the cecum. Angiography was performed demonstrating extravasation into the cecum from a branch of the right colic artery. Infusion of intraarterial pitressin resulted in cessation of bleeding, and this was continued for 48 hours. Two days after stopping the pitressin infusion, hematochezia recurred, and a colonoscopic examination revealed large edematous friable cecal folds. The bleeding had slowed and an epinephrine lavage (1:10,000) was undertaken. Biopsies of the cecum demonstrated acutely inflamed mucosa with areas of necrosis. No further bleeding was encountered and the patient was discharged without further complication on the ninth hospital day. The cecum is well recognized to be a relatively thin structure and susceptible to the transmural effects of thermal coagulation injury. A large review of the complications of the "hot biopsy" technique noted that 87% of resulting colonic perforations occurred in the cecum. 2 The variability of depth of injury has been well described3 • 4 and therefore cecal complications are not surprising. It is the onset of 418
Alan M. Nelson, MD Division of Gastroenterology Bridgeport Hospital Bridgeport, Connecticut
REFERENCES 1. Quigley EMM, Donovan JP, Linder J, Thompson JS, Straub PF, Paustian FF. Delayed massive hemorrhage following electrocoagulating biopsy ("hot biopsy") of a diminutive colonic polyp. Gastrointest Endosc 1989;35:559-63. 2. Wadas DD, Sanowski RA. Complications of the "hot-biopsy" forceps (HBF) technique. Gastrointest Endosc 1988;34:32-7. 3. Johnston JH, Jensen DM, Mautner W. Comparison of endoscopic electrocoagulation and laser photocoagulation of bleeding canine gastric ulcers. Gastroenterology 1982;82:902-10. 4. Swain CP, Mills TN, Shemesh E, et al. Which electrode? A comparison of four methods of electrocoagulation in experimental bleeding ulcers. Gut 1984;25:1421-31.
Ethanol-induced tumor necrosis to palliate esophago-gastric cancer To the Editor: We were interested in the report by Payne-James et al.' describing the use of ethanol in patients with advanced esophago-gastric cancer. In Blackpool, eight patients (five men) with esophageal cancer not treatable by surgery have received ethanol injection and dilation, using the technique described. In keeping with the high proportion of elderly residents in the area, their mean age was 77 years. The patients are summarized in Table 1. In all patients dysphagia was relieved, in seven after the first treatment. Two patients survived for 11 and 13 months after the onset of treatment and interestingly neither required dilation during the last 6 months of their lives, death occurring from multiple metastases. The eight patients received 17 sessions of injection sclerotherapy (1 to 4), 19 dilations (1 to 4). In no case was endoscopic intubation carried out. There were no major complications in this small series, although one patient (case 1) had transient atrial fibrillation shortly after the first treatment, but there was a previous history of severe ischemic heart disease. Mean survival of 156 days was comparable to other palliative measures including laser therapy and/or endoscopic intubation. Like Payne-James et al.' we can detect no evidence that injection therapy of carcinoma of the esophagus has any major drawbacks, taking into account the natural history of the primary disease. As they indicated, the equipment required is considerably less expensive and less elaborate than laser treatment and on the evidence to date the morbidity GASTROINTESTINAL ENDOSCOPY
Letters to the Ed itor New computer simulation study group formed To the Editor: The Computer Simulation Study Group was formed during the Digestive Disease Week Meeting in San Antonio, Texas. The goals of this group will include the development of equipment for computer-assisted teaching of endoscopic technique, and the assessment of devices concerning their potential for developing skills in gastrointestinal endoscopy. The long-term goals will encompass incorporation and evaluation of the motor and cognitive skills required for the safe and successful performance of endoscopy. The founding members are: John Baillie, Durham, N.C., Marc Beer-Gabel, Reims, France, Thomas Fabry, N.Y., N.Y., Duncan Gillies, London, U.K., Angelo Haritsis, LonVOLUME 36, NO.4, 1990
don, U.K., Mark Noar, Towson, Md., Jerome D. Waye, N.Y., and Christopher B. Williams, London, U.K. This study group will be a vehicle for communication of ideas and sharing of knowledge. Membership is open to anyone who has demonstrated commitment to this field by having developed a working computer system for teaching endoscopy. Meetings will be held at sites of gastrointestinal meetings. The next meeting will be held in Sydney, Australia, in August 1990. Christopher J. Barde, MD Department of Medicine (111) Dayton Veterans Administration Medical Center Dayton, Ohio
Sedation for upper gastrointestinal endoscopy: time for reappraisal? To the Editor: We read with interest the recent report by AI-Atrakchi,' who successfully performed 2000 upper gastrointestinal endoscopies without sedation. We would like to draw attention to a similar study, which we published in 1986. 2 In this study we used a preliminary test of pharyngeal sensitivity (the finger-throat test) and were able to predict (positive predictive value, 1.00; negative predictive value, 0.93) patient tolerance to endoscopic examination. Our paper 2 has been favorably criticized by Maratka. 3 Since the publication of our study,2 we have performed more than 3000 upper gastrointestinal endoscopies without sedation in most of our in-patients and out-patients, predicting their tolerance of the procedure by the finger-throat test. During this period (1986 to 1988), five trainees in gastroenterology performed a total of 1128 consecutive successful examinations (median, 125; range, 76 to 575) using forward-viewing endoscopes (Olympus Q or GIF-IT20). Sedation had to be used (intravenous diazepam) in 2.6 to 13.8% (median, 6.4%) of patients which is similar to the range of 1.6 to 12.0% reported by AI-Atrakchi' and Ladas and Raptis. 2 Only seven (0.6%) examinations failed. The toleration of the procedure, as it was reported by each of the five trainees, was excellent or satisfactory in most patients and poor in only 1.8 to 12.5% (median, 4.6%), which is also comparable to 7% and 1.8% reported by us 2 and AI-Atrakchi,' respectively. In addition, during the same period (1986 to 1988), using the finger-throat test, we were able to perform ERCP without (or with light) sedation (2.5 to 5 mg of intravenous diazepam) in a substantial number of patients (100 and 334, respectively), i.e., 16.1 and 53.7%, respectively, of a total of 622 ERCPs. We have even performed a small number of sphincterotomies without any sedation. We think it is time for reappraisal of systematically using sedation for upper gastrointestinal endoscopy. Since not all patients can tolerate peroral endoscopy without sedation, we recommend the use of a test to predict patient tolerance. Spiros D. Ladas, Constantine Giorgiotis, Prokopis Pipis, Christos Papaioannou,
MD MD MD MD 417
Pericles Tassios, MD Evangelia Karra, MD Sotos A. Raptis, MD Gastroenterology Unit Second Department of Internal Medicine-Propaedeutic Evangelismos Hospital Athens, Greece
delayed hemorrhage after hot biopsy treatment of diminutive polyps that is the emphasis of this communication as well as that of Quigley et al.' They raise significant questions regarding this technique, and the possible short-circuit effect resulting from mucosal contact of the metal shaft with the mucosa. I have no reason to believe that to be a contributing factor in this case. However, the need for caution and reserve on the power settings when working in the cecum needs to be underscored.
REFERENCES 1. Al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989;35:79-81. 2. Ladas SD, Raptis SA. Selection of patients for upper gastrointestinal endoscopy without sedation. The finger-throat test. Ital J GastroenteroI1986;18:162-5. 3. Maratka Z. Selection of patients for upper gastrointestinal endoscopy without sedation. The finger-throat test. Gastrointest Endosc 1987;33:405-6.
Delayed hemorrhage following "hot biopsy" of a diminutive colonic polyp To the Editor: I read with great interest the recent report by Quigley et al.' describing the delayed onset of massive hemorrhage following polyp ablation using the hot biopsy technique in the cecum. A similar complication was recently encountered which underscores the concerns they have raised. A 59-year-old man had a colonoscopic evaluation elsewhere, during which a cecal diminutive polyp was encountered and treated by hot biopsy ablation. Biopsy ofthe lesion showed hyperplastic tissue. One week later, while visiting this area ofthe country, the patient presented with the acute onset of massive hematochezia and hypotension. The physical examination demonstrated no evidence of organomegally or stigmata of chronic liver disease. All clotting parameters were within normal limits. A bleeding scan utilizing technetium-labeled red blood cells demonstrated immediate localization in the cecum. Angiography was performed demonstrating extravasation into the cecum from a branch of the right colic artery. Infusion of intraarterial pitressin resulted in cessation of bleeding, and this was continued for 48 hours. Two days after stopping the pitressin infusion, hematochezia recurred, and a colonoscopic examination revealed large edematous friable cecal folds. The bleeding had slowed and an epinephrine lavage (1:10,000) was undertaken. Biopsies of the cecum demonstrated acutely inflamed mucosa with areas of necrosis. No further bleeding was encountered and the patient was discharged without further complication on the ninth hospital day. The cecum is well recognized to be a relatively thin structure and susceptible to the transmural effects of thermal coagulation injury. A large review of the complications of the "hot biopsy" technique noted that 87% of resulting colonic perforations occurred in the cecum. 2 The variability of depth of injury has been well described3 • 4 and therefore cecal complications are not surprising. It is the onset of 418
Alan M. Nelson, MD Division of Gastroenterology Bridgeport Hospital Bridgeport, Connecticut
REFERENCES 1. Quigley EMM, Donovan JP, Linder J, Thompson JS, Straub PF, Paustian FF. Delayed massive hemorrhage following electrocoagulating biopsy ("hot biopsy") of a diminutive colonic polyp. Gastrointest Endosc 1989;35:559-63. 2. Wadas DD, Sanowski RA. Complications of the "hot-biopsy" forceps (HBF) technique. Gastrointest Endosc 1988;34:32-7. 3. Johnston JH, Jensen DM, Mautner W. Comparison of endoscopic electrocoagulation and laser photocoagulation of bleeding canine gastric ulcers. Gastroenterology 1982;82:902-10. 4. Swain CP, Mills TN, Shemesh E, et al. Which electrode? A comparison of four methods of electrocoagulation in experimental bleeding ulcers. Gut 1984;25:1421-31.
Ethanol-induced tumor necrosis to palliate esophago-gastric cancer To the Editor: We were interested in the report by Payne-James et al.' describing the use of ethanol in patients with advanced esophago-gastric cancer. In Blackpool, eight patients (five men) with esophageal cancer not treatable by surgery have received ethanol injection and dilation, using the technique described. In keeping with the high proportion of elderly residents in the area, their mean age was 77 years. The patients are summarized in Table 1. In all patients dysphagia was relieved, in seven after the first treatment. Two patients survived for 11 and 13 months after the onset of treatment and interestingly neither required dilation during the last 6 months of their lives, death occurring from multiple metastases. The eight patients received 17 sessions of injection sclerotherapy (1 to 4), 19 dilations (1 to 4). In no case was endoscopic intubation carried out. There were no major complications in this small series, although one patient (case 1) had transient atrial fibrillation shortly after the first treatment, but there was a previous history of severe ischemic heart disease. Mean survival of 156 days was comparable to other palliative measures including laser therapy and/or endoscopic intubation. Like Payne-James et al.' we can detect no evidence that injection therapy of carcinoma of the esophagus has any major drawbacks, taking into account the natural history of the primary disease. As they indicated, the equipment required is considerably less expensive and less elaborate than laser treatment and on the evidence to date the morbidity GASTROINTESTINAL ENDOSCOPY