Endoscopist-directed administration of propofol: a worldwide safety experience.

BACKGROUND & AIMS: Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS: We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS: A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million. CONCLUSIONS: EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Incidence and predictors of "late" recurrences after endoscopic piecemeal resection of large sessile adenomas.

BACKGROUND: Large sessile colorectal adenomas (>/=2 cm in size) resected piecemeal have a 0% to 55% rate of residual adenoma at the first follow-up. Guidelines recommend inspection of the polypectomy site 3 to 6 months after resection. Some patients with a negative examination at 3 to 6 months have a subsequent "late" recurrence. OBJECTIVE: Our aim was to describe long-term follow-up of large sessile adenomas after piecemeal resection and to report the incidence and predictors of "late" recurrence. DESIGN: A retrospective study. SETTING: A tertiary-referral center. PATIENTS AND INTERVENTIONS: Large sessile colorectal adenomas were identified through an endoscopic database. Polyps were resected by piecemeal technique; flat areas that could not be snared were treated with argon plasma coagulation. Patients who completed follow-up examinations at our center 3 to 6 months and at least 1 year after initial resection were included. MAIN OUTCOME MEASUREMENTS: "Late" adenoma recurrence. RESULTS: Of 136 polyps with complete follow-up, 24 (17.6%) had macroscopically evident residual adenoma at follow-up, including 18 at the first follow-up and 6 (4.4%) with a "late" recurrence. Among 94 polyps with no visible adenoma and with negative biopsy specimens of the scar at the first follow-up, 92 polyps (97.9%) were eradicated at late follow-up, compared with 36 of 42 (85.7%) of the remaining polyps (P = .005). LIMITATION: A retrospective design. CONCLUSION: Our results confirm the phenomenon of "late" recurrences after endoscopic piecemeal resection of large sessile adenomas. However, a normal macroscopic appearance of the polypectomy site and negative scar biopsy specimens at the first follow-up is predictive of long-term eradication.

Considerations regarding the present and future roles of colonoscopy in colorectal cancer prevention.

Effective and safe colonoscopy is essential to colorectal cancer prevention, regardless of the method used for colorectal cancer screening. The level of colorectal cancer incidence reduction provided by colonoscopy and polypectomy varies widely in available studies. There are several mechanisms by which colonoscopy might fail to prevent colorectal cancer, and some of the mechanisms might be overcome by simple currently available measures. Further, advances in colonoscope technology could enhance the effectiveness of colonoscopy or render it less operator-dependent. The large market for colorectal cancer screening in the United States has spawned innovative noncolonoscopic technologies for colorectal cancer and polyp detection. Because these technologies are diagnosis only, their overall impact on outcomes ultimately may be determined by whether they successfully increase adherence to screening (which should reduce colorectal cancer incidence) versus displace patients from colonoscopy screening (which potentially could increase colorectal cancer incidence), as well as their cost effectiveness and the extent to which they reduce colonoscopy complications. As these strategies emerge, monitoring their effects on adherence, cancer prevention, and procedural complications will be needed to optimize their roles relative to primary colonoscopy screening.

Gastroenterologist-directed propofol: an update.

Gastroenterologist directed propofol has been proven safe in more than 220,000 published cases. Administration of low doses of opioid and/or benzodiazepine ("balanced propofol sedation") is the safest format for gastroenterologist directed propofol. Specific training is needed to undertake gastroenterologist directed propofol administration.

Immunomodulator and Biologic Agent Effects on Sleep Quality in Patients With Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) can disrupt normal sleep physiology and amplify a negative perception about quality of life. Evidence suggests increased circulation of inflammatory cytokines, such as tumor necrosis factor-alpha and interleukin-1, may play a role. METHODS: A total of 56 patients completed the Pittsburgh Sleep Quality Index (PSQI) to measure 7 sleep domains: sleep quality, sleep latency, sleep duration, sleep efficacy, sleep disturbance, sleep medications, and daytime dysfunction. Domain scores were summed to determine the presence or absence of sleep impairment. We compared patients taking immunomodulators or biologic agents to patients not on immunomodulator or biologic agent therapy. Demographics and IBD-related clinical information were collected to adjust for potential confounders that may secondarily affect sleep, such as body mass index, depression/anxiety, and sleep-affecting medications. RESULTS: The majority of patients with IBD (46 [82%]) reported poor sleep quality; 22 (79%) of the patients taking immunomodulators or biologic agents and 24 (86%) of the patients not on these therapies had a global PSQI score ≥5, suggestive of poor sleep quality. However, we found no significant difference between the 2 groups. When we analyzed the 7 PSQI sleep domains individually, we found improved sleep duration in the group taking immunomodulators or biologic agents compared to the group not on therapy, although the difference was not statistically significant. CONCLUSION: The majority of patients with IBD experience some degree of sleep impairment, and treatment with immunomodulators and biologic agents does not appear to improve sleep quality. A multicenter study with a larger sample size is warranted to better assess the diverse population of patients with IBD and the factors that impact their sleep. Routine assessment of sleep quality during IBD clinical encounters is recommended.

Effects of Immunomodulators and Biologic Agents on Sexual Health in Patients With Inflammatory Bowel Disease.

BACKGROUND: Although much knowledge has been gained regarding the medical and surgical management of inflammatory bowel disease (IBD), a paucity of information is available on the psychosexual issues related to IBD. The aim of this study was to evaluate the sexual health of patients with IBD who were taking immunomodulators and/or biologic agents vs patients with IBD who were not on that medication regimen. METHODS: All study participants completed a validated sexual health questionnaire, the Female Sexual Function Index or the International Index of Erectile Function, to assess their subjective perception of the effect of IBD on the different domains of sexual function during the prior 1-month time period. RESULTS: No statistically significant differences in any baseline demographic variables were found for either sex between the group taking immunomodulators/biologic agents and the nontreatment group. Among females and males, individual question responses, domain scores, and total scores showed no statistically significant differences between the 2 treatment groups. CONCLUSION: Our data suggest that the use of immunomodulators or biologic agents does not affect female or male sexual health. However, treatment of patients with IBD must be individualized based on the aggressive nature of the disease, treatment goals, and the tolerability of various medications.

Isolated Gastrointestinal Sarcoidosis Involving Multiple Gastrointestinal Sites Presenting as Chronic Diarrhea.

Sarcoidosis is a chronic and systemic disorder characterized by the formation of non-caseating granulomas. Very few cases of isolated gastrointestinal sarcoidosis have been reported, and even fewer, if any, report gastrointestinal sarcoidosis within multiple gastrointestinal sites concomitantly. We present a 42-year-old white man with chronic diarrhea and abdominal pain for more than 3 years. Mucosal biopsies revealed non-caseating microgranulomas in the stomach, throughout the small intestine, colon, and rectum. Prednisone therapy was initiated with a rapid improvement in symptoms and complete resolution of diarrhea within 3 weeks.

Providing Our Fellows in Training with Education on Inflammatory Bowel Disease Health Maintenance to Improve the Quality of Care in Our Health Care System.

BACKGROUND: Inflammatory bowel disease (IBD) quality measures were established in an effort to standardize IBD health care. Despite effort to improve clinical performance, considerable variations in practice still exist. To further improve IBD health care, we propose incorporating an in-service educational session on IBD health maintenance to provide trainees with increasing awareness and knowledge on IBD management. METHODS: Fifty electronic medical charts were randomly selected, and the level of quality documentation was assessed for 15 core IBD quality measures. Data were reported as the percentage of charts meeting audit criteria (compliance score). Fellows then attended an in-service educational session to review IBD quality measures and reinforce practice expectations. A second audit was then performed on an additional 50 patient charts to determine whether documentation practices improved after the educational session. RESULTS: We found a positive correlation between an in-service educational session and fellows' compliance with IBD health maintenance. Overall, the fellows' compliance score increased by 18% (before intervention, 65%; after intervention, 83%; P < 0.0001). The intervention was equally beneficial irrespective of training level. Although the magnitude of improvement was comparable, the mean compliance score was highest in year 2 at 81% (year 1: 72% [P = 0.019] and year 3: 70% [P = 0.002]). Fellows expressed a high degree of satisfaction with the educational intervention and emphasized the value in reviewing the conceptual bases for IBD health maintenance. CONCLUSION: Incorporating a standard curriculum on IBD health maintenance provides fellows in training with increased awareness and guidance on managing the unique preventive care needs of patients with IBD.

Large cell neuroendocrine carcinoma of the rectum presenting with extensive metastatic disease.

Introduction. Rectal large cell neuroendocrine carcinoma (LCNEC) is a poorly differentiated neoplasm that is very rare and belongs within the poorest prognostic subgroup among primary colorectal neoplasms. Here, we describe a case of LCNEC of the rectum, which highlights the aggressive clinical course and poor prognosis associated with this disease. Case Presentation. We report a case of a 63-year-old male who presented to our hospital with a one-month history of lower abdominal pain, constipation, and weight loss. A computed tomography (CT) scan of the chest, abdomen, and pelvis revealed a rectal mass as well as metastatic disease of the liver and lung. Flexible sigmoidoscopy revealed a fungating, ulcerated and partially obstructing rectal mass located 6 cm from the anal verge. This mass was biopsied and pathological examination of the resected specimen revealed features consistent with a large cell neuroendocrine carcinoma. Conclusion. Rectal large cell neuroendocrine carcinomas are rare and have a significantly worse prognosis than adenocarcinomas. At diagnosis, a higher stage and metastatic disease are likely to be found. It is important to differentiate large cell, poorly differentiated neuroendocrine carcinomas from adenocarcinomas of the colon and rectum pathologically because patients may benefit from alternative cytotoxic chemotherapeutic regimens.