Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy.

Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed few significant differences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost effective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the definition used in this department.     

Importance of emergency fiber endoscopy in the diagnosis of hemorrhages from the upper parts of the digestive tract]

The work elucidates the role of the urgent fibroendoscopy in diagnosing hemorrhages from the upper parts of the gastro-intestinal tract. The urgent fibroendoscopy was performed in 121 patients with acute gastric hemorrhage. The cause of the hemorrhage was revealed in 111 patients (92%). In 25% (28 patients) the endoscopic examination has revealed additional changes, not responsible for hemorrhage. The endoscopic examination is most effective within the time of the proceeding hemorrhage.     

Caustic lesions of the upper digestive tract. Our experience]

The authors take into consideration 21 cases of caustic burns of the superior digestive tract. In 6 cases (29%) the extent of lesions has impelled emergency surgery. In case of total exeresis of the esophagogastric tract, according to their experience, the preferred operation is at closed thorax following the esophageal stripping technique.     

Sedation for endoscopy

A review of the recent literature reveals an increasing published opinion in favour of unsedated endoscopy. However, recent studies show that the majority of US patients are unwilling or unable to tolerate this. In order for there to be a shift towards unsedated endoscopy, physicians will have to change patients' expectations. The indications for diagnostic and therapeutic endoscopic procedures continue to expand, involving increasingly complex techniques that require a high degree of patient cooperation. There is still a need to refine the sedative regimen for these cases.     

Premedication for out-patient endoscopy of the upper gastro-intestinal tract

Upper gastrointestinal endoscopy was performed on 342 out-patients. The patients were allocated to four groups according to premedication given. The premedication used was atropine 0.1 mg/10 kg (A), atropine 0.1 mg/10 kg and diazepam 5 mg (AD), atropine 0.1 mg/10 kg and fentanyl 0.2 mg (AF), atropine 0.1 mg/10 kg diazepam 5 mg and fentanyl 0.2 mg (ADF). Premedication was given about 30 minutes before the procedure intramuscularly; the mouth and pharynx were sprayed with 10% lidoc,ine. The patients as well as the endoscopist considered the premedication in groups A and AD to be satisfactory. From the patient's point of view there were hardly any differences between the var;ous groups, except in drowsiness, which occurred more often in groups where fentanyl had been used. From the endoscopist's point of view groups A and AD were preferred because they offered better working conditions for the procedure. The longest period of observation was required in group ADF. On the basis of these results premedication with only atropine or if desired a combination of atropine and diazepam in addition to local sprayed anaesthesia of the mouth and pharynx is sufficient, and is recommended for endoscopy of the upper gastrointestinal tract.     

Caustic lesions of the upper digestive tract

A study of 108 patients who had ingested variable quantities of a caustic substance, most often for suicidal reasons. Hydrochloric acid was the substance most often encountered After stabilisation of any hemodynamic and respiratory disorders, all patients received emergency endoscopy. Subsequent therapy was based on the following endoscopic findings: --Patients, in whom the mucosa was normal, were not hospitalised. --The digestive tract of patients with stage I disorders was rested for 10 days. --Patients with stage III, disorders were operated on as an emergency especially when signs of gravity were present. --Patients with stage II disorders constituted the group which posed most problems in our study. These patients required enteral feeding as soon as possible, via a simple jejunostomy.     

Sedation for ambulatory endoscopy

Diagnostic and therapeutic fiberoscopy of gastrointestinal tract is often performed ambulatory and sedation is sometimes also required. Indication for sedation can be the intervention itself or the patient's psychological state. Aim of the study was to compare the effects of midazolam and combination of midazolam and fentanyl during endoscopy. Twenty eight cases were investigated: oesophagogastroduodenoscopy (n = 14) and colonoscopy (n = 14). Anaesthetics were midazolam (M) in 16 cases, midazolam-fentanyl (MF) in 12 cases. Non-invasive mean arterial pressure, pulse rate, acid-base balance and blood gases (by Astrup method) were recorded before endoscopy, at the 5th and 10th minutes of endoscopy, 15 minutes after intervention and also before emission. Pulse rate changed between 78-92/min. Mean arterial pressure appeared between 84-90 mm Hg. In MF group both were lower but there was not significant difference between the groups. The values were in normal range, there were not metabolic acidosis which needed correction. Onset of sedative effect was 2.8 min. in M group, 2.3 min. in MF group. The ability for adequate reaction returned within 11 min. in M group, within 14 min. in MF group. Fentanyl prolongs sedative effect of midazolam and offers sufficient pain relief. After 3 hours, patients could be emitted from the hospital.     

Present-day fiber endoscopy in the diagnosis and therapeutic tactics in foreign bodies of the upper digestive tract

Characterization of foreign bodies and their localization in the digestive tract in 404 patients is given. Surgical methods of treatment of such patients are described. Endoscopy was used for examination and treatment. The adequate anesthesia is thought by the authors to be necessary for a successful endoscopic removal of the foreign bodies. The indications for general anesthesia are enumerated. The endoscopic removal of the foreign bodies during surgical interventions are indicated in patients with the perforation of the esophagus by a foreign body.     

Sedation for upper gastrointestinal endoscopy: a comparison of alfentanil-midazolam and meperidine-diazepam

The authors studied the efficacy and cost of substituting sedation using midazolam and alfentanil for the existing regimen of diazepam and meperidine in patients requiring upper gastrointestinal endoscopy. Sixty consenting subjects were randomized to receive either meperidine 50 mg with diazepam approximately 90 μg · kg^{? 1} (Group D) or alfentanil 250 μg with midazolam approximately 50 μg · kg^{? 1} (Group M). Endoscope insertion time, patient acceptance, apnoeic or desaturation episodes were noted by a physician observer. Pulse oximetry was used to monitor heart rate and oxygen saturation (SpO₂) during endoscopy. Subjects performed four- choice reaction time (4CRT) tests before, 30 and 60 min after endoscopy, and were assessed for nausea or dizziness and their ability to stand and walk. During endoscopy, insertion time was shorter (84 ± 45 sec vs 122 ± 83 sec, P < 0.03) and fewer aversive movements occurred (0.4 ± 0.6 vs 1.7 ± 2.4, P < 0.005) in Group M than Group D. No subject in either group suffered any apnoea or prolonged desaturation requiring supplemental oxygen. Irrespective of treatment group, greater decreases in SpO₂ (6.1 ± 3.4% vs 3.6 ± 2.2%, P < 0.001) occurred in subjects > 45 yr of age than in subjects <- 45 yr. During recovery 4CRT values at 30 min after endoscopy were longer (723 ± 226 msec vs 594 ± 139 msec, P < 0.005) in Group M than in Group D but not after 60 min. It was concluded that the small differences in endoscopy conditions and greater sedation during the first 30 min of recovery did not justify the additional cost of using midazolam and alfentanil.     

Flumazenil in the outpatient A study following midazolam as sedation for upper gastrointestinal endoscopy

Fifty outpatients who underwent upper gastrointestinal endoscopy under midazolam sedation were allocated randomly into two equal groups of 25 in this double-blind study. After the endoscopy, and 30 minutes after administration of the sedative, patients in one group received flumazenil 0.5 mg; those in the other group received a similar volume of vehicle only. Assessments of memory function, psychomotor performance and coordination were carried out and these were repeated 3.5 hours later. Flumazenil produced a significant improvement (p less than 0.001) immediately but no difference could be detected between flumazenil and placebo at 3.5 hours. However, patients in the flumazenil group reported, by means of linear analogue scales, a subjective feeling of alertness at the time of discharge, which was greater than that reported by those in the placebo group (p less than 0.005).     

Sedation with intravenous midazolam during upper gastrointestinal endoscopy--changes in hemodynamics, oxygen saturation and memory

BACKGROUND: Cardiorespiratory adverse effects are often observed in patients undergoing upper gastrointestinal endoscopy with sedation. In this study, we examined hemodynamics, oxygen saturation and memory during upper gastrointestinal endoscopy under sedation with intravenous midazolam. METHODS: Eight healthy outpatients without any obvious complications received intravenous midazolam 5 mg for sedation for upper gastrointestinal endoscopy. Blood pressure, heart rate and percutaneous arterial oxygen saturation (SpO2) were measured before, during and after endoscopy. After the arousal by intravenous flumazenil, we inquired the patients about the level of memory during the endoscopy. RESULTS: Blood pressure decreased significantly two minutes after midazolam administration, but increased significantly after the insertion of an endoscope which was not different from the control value. Heart rate increased significantly one and three minutes after the insertion of the endoscope. SpO2 decreased significantly after midazolam administration and stayed at around 95%. No patients remembered the procedure. CONCLUSIONS: Sedation with intravenous midazolam during upper gastrointestinal endoscopy is useful to control the cardiovascular responses, and to obtain amnesia. However, a decrease in SpO2 should be watched carefully.