Safety of gastroenterologist-guided sedation with propofol for upper gastrointestinal therapeutic endoscopy in elderly patients compared with younger patients.

BACKGROUND/AIMS: Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy. METHODS: The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups a younger group, patients <75 years old; and an elderly group, patients ≥75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment. RESULTS: Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a re-sedated state after the initial recovery from sedation. CONCLUSIONS: Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.

Non-anesthesiologist administrated propofol (NAAP) during endoscopic submucosal dissection for elderly patients with early gastric cancer.

BACKGROUND: Propofol is rapidly increasing in use in many countries because endoscopists and patients report greater satisfaction with propofol than with conventional sedatives. However, propofol infusion during lengthy endoscopic procedures in elderly patients is still controversial. We investigated the safety of gastroenterologist-guided propofol sedation in elderly patients who underwent gastric endoscopic submucosal dissection (ESD) at a single center. METHODS: We reviewed 121 medical records of patients who underwent gastric ESD. We compared retrospectively the details of propofol usage, hemodynamics, and re-sedation in the elderly group to those in a younger group. RESULTS: No significant differences in patients' baseline characteristic including ASA classification between elderly and younger groups were shown. The average maintenance dose and total dose of propofol infusion could be similarly administrated in both groups. Seven adverse events (5.8 %) occurred at the time of propofol bolus injection. Although 3 cases (2.5 %) of hypotension (systolic blood pressure <80 mmHg), 8 cases (6.6 %) of desaturation (blood oxygen saturation <90 %) and 1 case (0.8 %) of bradycardia (pulse rate <40) were found during the maintenance of propofol infusion, there were no statistically significant differences in the elderly and younger groups. All events were immediately resolved without any intervention. No patients developed a re-sedated condition. CONCLUSION: Gastroenterologist-guided propofol sedation during gastric ESD may be acceptable even in the elderly with ASA classification I/II under careful monitoring of vital signs and oxygen saturation.

Comparison of hemostasis using bipolar hemostatic forceps with hemostasis by endoscopic hemoclipping for nonvariceal upper gastrointestinal bleeding in a prospective non-randomized trial.

BACKGROUND: We previously reported on the safety and efficacy of bipolar hemostatic forceps for treating nonvariceal upper gastrointestinal (UGI) bleeding. However, no prospective or randomized studies have evaluated the efficacy of bipolar hemostatic forceps. The aim of this study was to evaluate the hemostatic efficacy of using bipolar hemostatic forceps compared with the hemostatic efficacy of the commonly used method of endoscopic hemoclipping for treating nonvariceal UGI bleeding. METHODS: A total of 50 patients who required endoscopic hemostasis for UGI bleeding were divided into two groups: those who underwent endoscopic hemostasis using bipolar hemostatic forceps (Group I) and those who underwent endoscopic hemostasis by endoscopic hemoclipping (Group II). We compared the two groups in terms of hemostasis success rate and time required to achieve hemostasis and stop recurrent bleeding. RESULTS: All (100 %) of 27 patients in Group I and 18 (78.2 %) of 23 patients in Group II were successfully treated using bipolar hemostatic forceps or by endoscopic hemoclipping alone, respectively, indicating a significantly higher success rate for Group I than for Group II (p < 0.05). The time required to achieve hemostasis was 6.8 ± 13.4 min for Group I and 15.4 ± 17.0 min for Group II. One patient in Group I (3.7 %) and four patients in Group II (22.2 %) experienced recurrent bleeding. CONCLUSION: Bipolar hemostatic forceps was more effective than endoscopic hemoclipping for treating nonvariceal UGI bleeding.

Mucosal cutting biopsy technique for histological diagnosis of suspected gastrointestinal stromal tumors of the stomach.

BACKGROUND AND AIM: The Japanese Gastrointestinal Stromal Tumor (GIST) therapeutic guidelines recommend endoscopic ultrasound-guided fine-needle aspiration biopsy for histological diagnosis. However, before 2010, this technique was only carried out at a minority of medical institutions in Japan. In the present study, we investigated the usefulness of mucosal cutting biopsy. METHODS: In 18 asymptomatic gastric submucosal tumors, mucosal cutting biopsies were carried out. We examined tumor size, tumor site (lower third: L; middle third: M; upper third: U), histopathological diagnostic yield and complications. In cases that proceeded to surgical resection with a diagnosis of GIST, we compared the pre- and postoperative histopathological diagnosis, and the histological degrees of malignancy. RESULTS: The tumors had a mean size of 20.3 mm and were located at the L site in five cases, M in four, and U in nine. Histological diagnosis of submucosal tumor was obtained in all the cases. (GIST, n = 13; heterotopic pancreas, n = 2; and leiomyoma, n = 3). No complications (e.g. bleeding, perforation or peritonitis) were seen after this procedure. In all 11 patients with GIST who underwent surgical resection, the histopathological findings from the mucosal cutting biopsy specimens were similar to those from the surgically resected specimens, with agreement between the immunostaining findings and the histological degree of malignancy (90.9%) in 10 patients. CONCLUSIONS: The mucosal cutting biopsy technique is a useful diagnostic modality for the diagnosis of gastric GIST and for selection of the appropriate treatment.

[A case of pseudomembranous colitis concomitant with toxic megacolon and paralytic ileus].

A 60-year-old man was diagnosed as pseudomembranous colitis with chief complaint of fever and abdominal distension after a cerebral operation. It was ineffective although vancomycin hydrochloride (VCM) was given orally. Complications occurred. The patient had toxic megacolon and paralytic ileus. VCM was administrated via an ileus tube. In addition, the bowel was lavaged and VCM was sprayed by colonoscopy. This therapy was very effective. Generally, a patient with pseudomembranous colitis concomitant with toxic megacolon or/and paralytic ileus is considered to have a poor prognosis, however, he completely recovered by a combination of medical treatment.

Clinical evaluation of emergency endoscopic hemostasis with bipolar forceps in non-variceal upper gastrointestinal bleeding.

The present study was designed to evaluate the usefulness and safety of bipolar hemostatic forceps, known as a less invasive and highly safe means of thermal coagulation used for hemostasis in cases of non-variceal upper gastrointestinal bleeding. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis. The study involved 39 cases where hemostasis was attempted with bipolar forceps to deal with non-variceal upper gastrointestinal bleeding, including 28 cases of gastric ulcer, six cases of duodenal ulcer, three cases of bleeding after endoscopic submucosal dissection (ESD), one case of Mallory-Weiss syndrome and one case of postoperative bleeding from the anastomosed area. There were 34 males and five females, with a mean age of 63.6 years. Bipolar forceps were the first-line means of hemostasis in cases of oozing bleeding (venous bleeding), pulsatile or spurting bleeding (arterial bleeding) and exposed vessels without active bleeding. The primary hemostasis success rate was 92.3%, and the re-bleeding rate was 0%. In cases where the bleeding site was located along the tangential line or in cases where large respiration-caused motions hampered identification of the bleeding site, hemostasis by means of coagulation was easily effected by application of electricity while the forceps were kept open and compressed the bleeding area. In addition, there were no complications. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis.

A study on bone mineral density in patients with Crohn's disease.

Decreased bone mineral density is a complication to which we should always pay attention in the treatment of Crohn's disease (CD). However, there is still no clear consensus with regard to evaluation methods and the appropriate observation period for its detection. In the present study, we measured the bone mineral density of 30 CD patients who were treated at the outpatient clinic of our institution and investigated its relationship with various clinical characteristics including sex, age, duration of illness, history of enterectomy, total steroid consumption, body weight, and body mass index (BMI) and with bone metabolism markers. A decreased bone mineral density was detected in 9 patients (30%). The bone mineral density did not correlate with total steroid consumption, but showed a negative correlation with the Crohn's disease activity index (CDAI).When bone metabolism markers were investigated, the bone mineral density showed a negative correlation with Glu-osteocalcin (Glu-OC) and serum type I collagen cross-linked N-telopeptide (NTx) in patients with a low bone mineral density. Based on these results, the decrease of bone mineral density in CD patients was considered to the underlying disease itself. Therefore, control of disease activity is very important in CD patients, and periodic measurement of bone mineral density in combination with bone mineral markers (Glu-OC and serum NTx) may be useful for predicting a decrease of bone mineral density.

[A case of intractable chronic abdominal pain caused by hepatomegaly associated with primary amyloidosis, successfully treated with celiac plexus block].

A 51-year-old female previously diagnosed as primary amyloidosis suffered from recurrent abdominal pain. The result of thorough examination indicated that the main cause of the pain was severe hepatomegaly. Continuous venous administration of narcotics and other alternative therapies did not provide symptomatic relief, and thus the patient was treated with celiac plexus block, which resulted in effective pain control and improved ADL level. Though the procedure of celiac plexus block is simple and celiac plexus block is applicable without causing severe complication, it is not widely used. From this case, it is considered that celiac plexus block is one of the most effective means to relieve intractable pain associated with both benign malady and abdominal malignant tumor.

[A case of recurrent esophageal cancer with lung metastases successfully treated with docetaxel-combination chemotherapy].

We report a case of a 67-year-old woman diagnosed with advanced esophageal cancer. She was treated with chemo-radiotherapy (5-FU/CDDP therapy and irradiation) initially, and primary lesion was well controlled. Two and a half years after first treatment, a chest CT showed multiple lung metastasis, which were confirmed by thoraco-laparoscopy. We chose docetaxel/CDDP combination chemotherapy, because of severe side effects due to the first treatment. After 3 courses, lung metastatic lesions were reduced. The following courses combining docetaxel-nedaplatin were done as ambulatory treatment. These regimens could be one choice for recurrent esophageal cancer, especially FP therapy-resistant or intolerant cases.