Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study.

BACKGROUND AND STUDY AIMS: Propofol sedation is increasingly being used for endoscopy in the outpatient setting. In view of the agent's short period of action, current recommendations that patients should avoid driving or using public transport unescorted for 24 h may be too strict. Psychomotor recovery and driving skills before and after sedation were therefore assessed. PATIENTS AND METHODS: A total of 100 patients undergoing routine upper or lower gastrointestinal endoscopy were randomly sedated either with propofol alone or with midazolam plus pethidine. The recovery time and quality of recovery were assessed. Psychomotor recovery was evaluated using the number connection test (NCT) and a driving simulator test 1 h before and 2 h after the endoscopic procedure. RESULTS: Ninety-six patients completed the 2-hour post-sedation procedure. Vital signs were recorded, and no clinically relevant complications occurred. The mean recovery time and quality of recovery were significantly better after propofol sedation (14 +/- 9 min vs. 25 +/- 8 min and 8.7 +/- 1.3 vs. 6.3 +/- 1.1 points) ( P < 0.01). Psychomotor and driving skills after propofol sedation were similar to the baseline results, while in the midazolam/pethidine group, patients showed significantly more lane deviations (1.1 +/- 0.9 vs. 1.6 +/- 0.9), time over the speed limit (0.3 +/- 0.83 vs. 0.6 +/- 0.88), missed stoplights more often (0.05 +/- 0.31 vs. 0.11 +/- 0.35), and had slower reaction times for unexpected events (1.11 +/- 0.46 s vs. 1.39 +/- 0.44 s) ( P < 0.01). The time needed to complete the NCT after sedation did not differ between the two groups (32.1 +/- 12.0 s vs. 33.4 +/- 12.6 s for propofol; 31.5 +/- 11.2 s vs. 34.6 +/- 12.8 s for midazolam/pethidine). CONCLUSIONS: Current recommendations that patients should refrain from driving and unescorted use of public transport for 24 h after sedation may need to be reconsidered in patients who receive propofol sedation.

Intraductal ultrasonography in the diagnosis of Mirizzi syndrome.

BACKGROUND AND STUDY AIMS: Common bile duct (CBD) compression can be caused by stones in the cystic duct (Mirizzi syndrome) which can be difficult to diagnose even with endoscopic retrograde cholangiopancreatography (ERCP). Conventional imaging often gives insufficient information and endoscopic ultrasonography (EUS) and magnetic resonance imaging may improve diagnostic accuracy, but often the final diagnosis is made during exploratory surgery. PATIENTS AND METHODS: All patients undergoing ERCP during a 3-year period were prospectively analyzed if they fulfilled the inclusion criteria: gallbladder in situ; obstructive jaundice with CBD stenosis, demonstrated at endoscopic retrograde cholangiography (ERC), but unexplained at ultrasonography; and inability to demonstrate the cystic duct during ERC. Intraductal ultrasonography (IDUS) was carried out over a guide wire using a 20-MHz probe. Prior to ERCP, patients were evaluated with abdominal ultrasonography and computed tomography (CT), as well as by magnetic resonance cholangiopancreatography (MRCP) or EUS in some. RESULTS: 74 patients out of 2089 undergoing ERCP fulfilled the entry criteria. Final diagnoses, from surgical exploration (n = 41), cytology (n = 21), or endoscopic extraction of stones from the cystic duct (n = 12), were Mirizzi syndrome (type I) in 30 patients and other causes in 44 patients (gallbladder carcinoma [n = 16], pancreatic carcinoma [n = 9], metastatic compression [n = 9], other [n = 10]). CT had shown suspected Mirizzi syndrome in 1/30 cases (3 %) and MRCP in 12/19 evaluated cases (63 %). EUS allowed a correct diagnosis in 11 of 15 evaluated cases (73 %). IDUS required an additional 8 +/- 3 min and showed a sensitivity of 97 % and specificity of 100 %. CONCLUSION: IDUS is a sensitive and specific method for the diagnosis of Mirizzi syndrome.

Reduction of miss rates of colonic adenomas by zoom chromoendoscopy.

BACKGROUND AND AIMS: The aim of this study was to determine the detection rate of polyps using zoom chromoendoscopy (ZE) compared with standard video colonoscopy. PATIENTS AND METHODS: End-to-end colonoscopies were performed in 50 patients by two different endoscopists blinded for each other's results. Lesions detected during initial standard colonoscopy (C1) were biopsied or removed by snare resection. The second colonoscopy (C2) was done with a zoom colonoscope spraying the whole colon with indigocarmine (0.4%). In addition, detected mucosal lesions were documented prior to ZE and then classified according to the pit pattern classification before biopsy or removal. The retrieval time for each procedure was determined. RESULTS: The average retrieval time for C1 was 13+/-9 min (9-24) and 28+/-11 min (16-38, p<0.05) for ZE. During C1, 56 lesions were detected in 26 of 50 patients (34 hyperplastic and 22 adenomatous). During C2, 19 additional polyps were documented prior to ZE (15% tandem miss rate), and 20 further lesions were detected with ZE (21% additional polyp detection rate compared to C1 and C2 without ZE). Of the 39 additional lesions removed during C2 after ZE, 29 were hyperplastic and 10 were adenomatous. Most adenomas detected during the second investigation were found in patients in whom adenomatous polyps had already been removed during the initial colonoscopy (9 of 26 patients vs 1 of 24 patients, p<0.02). No carcinoma was detected. The pit pattern classification allowed a correct differentiation between hyperplastic and adenomatous polyps (accuracy 93%, sensitivity 90%, specificity 97%). CONCLUSION: Using zoom chromoendoscopy, the rate of detecting colonic polyps can be increased at the cost of a longer retrieval time.

Unusual malfunction of percutaneous endoscopic jejunostomy feeding tubes in patients with intestinal dysmotility.

We report the complication of knotted percutaneous endoscopic jejunostomy (PEJ) feeding tubes in three patients with intestinal dysmotility. The management of PEJ tube dysfunction and strategies to prevent this complication are discussed.

Reducing delays in the diagnosis and treatment of Clostridium difficile diarrhoea.

BACKGROUND: The diagnosis of Clostridium difficile diarrhoea is often delayed. AIM: To assess and reduce delays in diagnosis and treatment. DESIGN: Two-part study: retrospective audit then prospective observational. METHODS: The retrospective study audited cases positive for C. difficile culture or toxin A between June 2000 and January 2001. Cases were reviewed regarding demographic characteristics and the timing from onset of symptoms to testing and treatment (n = 27). In the prospective study, efforts were made to increase the awareness of medical staff about C. difficile diarrhoea, and testing for C. difficile toxin A assay was substituted for stool culture and external toxin analysis. Data were prospectively analysed for demographic characteristics and time from onset of symptoms to testing and treatment (n = 24). RESULTS: There were no significant differences in age (76 vs. 78 years), male to female ratio (1:2 vs. 1:4), reason for admission, specialty responsible, or mortality rate (40% vs. 37%) during the presenting admission. Preceding antibiotic use, the combination of antibiotics used and subsequent treatment also did not differ between groups. The time from onset of diarrhoea to sampling was reduced from 4.7 days (range 3-30) to 0.8 days (range 0-5; p