Anesthesia for complex endoscopy: a new paradigm
30 October 2014 (online)
Deep enteroscopy using overtube-assisted methods has been a major advance in endoscopy, allowing the inspection and treatment of small-bowel disorders   . Overtube-assisted endoscopy has also increased our ability to perform a myriad of other endoscopic interventions such as endoscopic retrograde cholangiopancreatography (ERCP), direct percutaneous jejunostomy, insertion of stents into previously unreachable areas of stenosis, and other extreme endoscopic interventions     . Traditionally, gastrointestinal (GI) endoscopy has been performed using conscious sedation. However, endoscopy has evolved into a broad-spectrum specialty, including standard diagnostic, low level therapeutic, and advanced interventional and therapeutic endoscopy. Whereas most cases of diagnostic and low level therapeutic interventions, such as colon polypectomy, esophageal dilation of simple strictures, and endoscopic mucosal resection, may be performed easily and safely using conscious sedation, the majority of advanced interventional and therapeutic interventions may need to be done with the patient under general anesthesia. Until now, the decision to use general anesthesia rested on individual preferences of the endoscopy team. There are scant data on the reasons and circumstances of when and how to use general anesthesia for advanced endoscopy procedures  .
In this issue of Endoscopy, Lara et al. from the USA elegantly and critically evaluate this aspect . The authors report on a quality improvement program that led to a change in the way deep enteroscopy is practiced in their endoscopy unit. The quality program of the authors’ endoscopy unit uncovered a significant number of respiratory adverse events leading to emergency resuscitation efforts in patients undergoing overtube-assisted enteroscopy. The authors undertook a retrospective study of prospectively obtained data of consecutive patients undergoing 432 overtube-assisted enteroscopy procedures performed with monitored anesthesia care (i. e. moderate or deep sedation) during a 4-year period. They found that a total of 15 severe adverse events had occurred in 14 patients, of whom 12 were outpatients, giving an incidence of 3.2 %. All but one had occurred during antegrade overtube-assisted enteroscopy. Whereas hypoxemia requiring mask ventilation was the most common adverse event, four patients required endotracheal intubation. Furthermore, 4 /12 outpatients had to be admitted to the intensive care unit. The procedure was aborted in all but one patient, and only 1 of 10 patients offered a repeat deep enteroscopy returned for the procedure. This could lead to a potentially serious problem being left untreated.
Based on these events that had occurred during monitored anesthesia care with moderate or deep sedation, the authors began to perform all anterograde overtube-assisted enteroscopies with patients under general endotracheal anesthesia. On a subsequent audit spanning a 12-month period there was no respiratory adverse event among 145 anterograde overtube-assisted enteroscopies. The authors concluded that a program of continuous monitoring of their endoscopy practice had identified adverse events associated with overtube-assisted enteroscopy. The peer-review process led to a change in practice which resulted in a dramatic decrease of adverse events related to overtube-assisted enteroscopy.
So, what are the key messages of this interesting paper? Are their findings applicable to other practice settings? Is this study going to change the way we practice complex endoscopy?
The first key message is that a quality improvement program was of paramount importance to detect adverse events. We strongly believe that any endoscopy unit should have an ongoing quality program to detect adverse events and patient outcomes. Current guidelines of the major endoscopic societies strongly recommend the institution of such programs. However, there are many limiting factors hampering the creation of quality improvement programs. First, many endoscopy units lack the personnel and economic capacity to support such a program. Nonetheless, this limitation can be overcome by strategic planning and creation of steps to ensure safety in the endoscopy unit. Adoption of safety checklists is an important initial step to avoid complications. An essential function of such checklists is to ensure communication between all members of the team providing care for the patient. Thus, the endoscopist and anesthesiologist should cooperate closely. In our endoscopy unit we have instituted a similar quality improvement program. The essential step was to create an endoscopy quality assurance team that encompassed the nurse-manager, endoscopist, anesthesiologist, and a dedicated office person who managed the data. Our team realized that the type and complexity of endoscopic procedures performed at our unit do not reflect those of a standard practice endoscopy unit or ambulatory endoscopy center. In our setting of a busy tertiary endoscopy unit, performing close to 1000 ERCPs, 2200 endoscopic ultrasounds, 200 endoscopic resections, 200 deep enteroscopies, and 250 cases of extreme endoscopy a year, we realized that conscious sedation was not a valid option in many of these endoscopies. It is our practice that all endoscopies anticipated to be long or complex are performed with general endotracheal anesthesia. Our approach is thus supported by the findings of Lara et al.
Would it be worthwhile or appropriate to perform a prospective, randomized study comparing conscious sedation versus general anesthesia for complex endoscopy? We know, based on this study  and the study by Guimaraes et al. , that the incidence of severe respiratory events is higher in patients undergoing complex endoscopy, whose procedure was performed with conscious sedation. Thus, such a prospective study would be hard to justify, especially considering the examples provided below in the following paragraphs.
Their second key message is the change in practice, in which all anterograde overtube-assisted enteroscopies were performed with patients under general endotracheal anesthesia. Whereas some may consider this to be excessive and may still promote moderate sedation for deep enteroscopy, we strongly believe that this paper is delivering the following message: “patients undergoing complex upper GI endoscopic procedures should receive general endotracheal anesthesia.”
GI endoscopy has evolved from a specialty dedicated to diagnosis by visualization or removal of tissue by biopsy forceps, to one with a large variety of moderately and highly complex interventions. These interventions include deep enteroscopy, resection of large tumors, level III and IV ERCP, and extreme endoscopy      . Many of these interventions are very lengthy, require the use of overtubes, large quantities of accessories and, often, exchange of scopes or even dual-endoscopic techniques . For many of these procedures we do not even consider conscious sedation. It would be irresponsible to use conscious sedation when attempting to remove a foreign body in a patient who had swallowed multiple blunt and sharp objects, or even in a young patient with increased gag reflex who had presented for food disimpaction in the setting of suspected eosinophilic esophagitis, as these circumstances may increase the risk of aspiration pneumonia or esophageal rupture . Likewise, placement of duodenal or pyloric stents in patients with gastric outlet obstruction or performance of emergency endoscopy in a patient with liver cirrhosis and upper GI bleeding should not be done without airway protection by an endotracheal tube. In any patient suspected of having a full stomach, it will always be safer to perform a rapid sequence induction of anesthesia with endotracheal intubation. The endoscopist can then concentrate on the endoscopic procedure with a well-anesthetized patient without worrying about movement, retching, gagging, and regurgitated gastric contents.
And finally, the authors continued to monitor their practice and evaluated whether the change instituted really led to the desired absence of severe respiratory complications.
There are some potential deficits in this study and some questions that require further or future clarification. The authors performed only two ERCPs by means of overtube- assisted enteroscopy. We suspect that more adverse events would have occurred if the number of overtube-assisted ERCPs had been higher. These cases can last 120 to 150 minutes, and they should be done under general anesthesia. We found it interesting that in a noteworthy proportion of cases the respiratory event occurred before the scope and overtube had passed the ligament of Treitz. Here, it is possible that the overtube created pressure on the trachea, limiting the patient’s ability to breathe. It is also possible the anesthesia provider was overly aggressive during the induction and administered too much propofol.
We want to emphasize that GI endoscopy anesthesia is a relatively new field and most anesthesiologists have not had substantial experience in dealing with GI endoscopies. The significant involvement of anesthesia services in the GI suite has arisen from several events. In the USA, the Centers for Medicare and Medicaid Services (CMS) in 2009 ruled that all anesthesia services in a hospital should be organized into a single anesthesia service as a condition of participation . In 2010 the Food and Drug Administration (FDA) denied a request for removal of a “black box” warning on propofol that indicated that its use be limited to those trained in administration of general anesthesia and not involved in the conduct of the procedure. These events led to limitation of the use of propofol by GI endoscopists. At our institution the hospital sedation policy was changed such that propofol, etomidate, and ketamine were excluded from use by nonproviders of anesthesia. Regardless of some of the above reasons, we believe that a hospital-based endoscopy unit performing advanced interventional endoscopy should have the anesthesia services providing sedation and anesthesia for these complex cases, in order to ensure procedural success and patient safety.
How often have we attended live endoscopy meetings to find that all complex cases, including deep enteroscopies, are performed using general anesthesia? Later we find out that this practice was only set in place for the course and that during the daily routine the majority of cases are performed using conscious sedation, with substandard monitoring, and with nursing staff providing procedural sedation while other staff in the room hold the patient down while the deep enteroscopy or ERCP is performed. The door to the procedure room is often closed to prevent the moans of the inadequately sedated patient from being transmitted outside the room. Is this appropriate and safe care for the patient? We feel it is not.
Other studies on deep enteroscopy have not reported such a high incidence of respiratory adverse events . Thus, it is possible that the high event rate reported by Lara et al. is a local phenomenon. However, we believe that there is a reporting bias, with the majority of studies failing to report on respiratory events, mainly because these studies have focused on endoscopy-related events. Nonetheless, aspiration pneumonia is an adverse event that can occur in patients undergoing overtube-assisted direct jejunostomy .
Are the findings of Lara et al applicable to other practice settings?
The answer is a clear “yes.” Their findings clearly apply to all tertiary centers performing deep enteroscopy. As advanced endoscopic procedures are increasingly complex and lengthy and are performed in an increasingly sicker patient population, it makes good sense to have the sedation/anesthesia services provided by the anesthesia department.
More importantly, their findings do not apply to outpatient endoscopy centers, where mainly diagnostic upper and lower endoscopic procedures are done. Having an anesthesia provider administering sedation in this setting is of questionable benefit and may be “overtreatment.” Nonetheless, certain patients presenting for “routine” upper and lower endoscopy may benefit, because of their underlying medical conditions, from provision by the anesthesia care team of sedation/anesthesia services. These include patients with morbid obesity, obstructive sleep apnea, chronic use of narcotics, and severe cardiovascular disease.
Is this study going to change the way we practice complex endoscopy? We believe that this paper has definitely sent some clear messages and a new paradigm for sedation in complex endoscopy: (i) a quality assurance program is a must in any endoscopy unit, and (ii) complex endoscopic procedures should be performed by a team led by endoscopist and anesthesiologist. Having a well-sedated/anesthetized, still patient allows better conditions for the proceduralist. It also allows the proceduralist to focus on the procedure and not be responsible for both sedation and the procedure. We need to realize that advanced, interventional endoscopies are strenuous interventions that impact patient safety and outcomes. Therefore, all necessary steps to assure a successful intervention and prevent a bad outcome should be followed.
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