Reply to Sbaraglia et al.

 

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In response to the letter from Sbaraglia et al., we agree that current endoscopic techniques blur the lines of surgery [1]. These procedures are prolonged, may expose the patient to higher risks of aspiration, hypothermia, fluid and electrolyte imbalances, and pain, and risks associated with any sudden movement. It is time to recognize this for the sake of patient wellbeing and thus approach these with a “patient first” mindset, which in our case now involves general anesthesia not only for antegrade overtube-assisted enteroscopy but also for endoscopic Zenker’s diverticulotomies, endoscopic submucosal dissection, etc. We rarely perform routine endoscopies, including ERCP and endoscopic ultrasound, with general anesthesia.

We are indeed fortunate to work at a place where multidisciplinary care is readily available, reflected by the synergy between endoscopy and anesthesia which makes it very easy to schedule complex cases. Propofol administration is more of an art, administered until adequate sedation is achieved, rarely prescribed by weight-based doses, and quite safe [2] [3] [4]. Since the vast majority of the procedures at our institution are performed with propofol sedation administered by board-certified anesthesia providers (anesthesiologist or anesthetist under supervision), all of our anesthesia providers are familiar with our endoscopic interventions. We anticipate a need for general anesthesia for complicated endoscopies, and especially for patients with significant co-morbidities, so the decision to perform endotracheal intubation is made a priori, and sometimes an anesthesia consultation is obtained before the procedure for high risk patients to anticipate any needs at time of the procedure.

We agree that generalizing an approach to sedation is not appropriate, and we were careful to avoid a blanket statement that all antegrade overtube-assisted enteroscopies should be done under general anesthesia, but our data and the accompanying editorial bring attention to the issue of sedation, and that this must be part of the evaluation of risks associated with complex endoscopies [1] [5].

• References

• 1 Lara LF, Ukleja A, Pimentel R et al. Effect of a quality program with adverse events identification on airway management during overtube-assisted enteroscopy. Endoscopy 2014; 46: 927-932
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• 2 Vargo JJ, Cohen LB, Rex DK et al. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Am. J. Gastroenterol 2009; 104: 2886-2892
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• 3 Vargo JJ, Holub JL, Faigel DO et al. Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy. Aliment Pharmacol Ther 2006; 24: 955-963
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• 4 Rex DK, Heuss LT, Walker JA et al. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology 2005; 129: 1384-1391
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• 5 Phillips MC, Mönkemüller K. Anesthesia for complex endoscopy: a new paradigm. Endoscopy 2014; 46: 919-921
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