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CC BY-NC-ND 4.0 · Endosc Int Open 2024; 12(01): E1-E10
DOI: 10.1055/a-2180-8880
Original article

Safety and efficacy of physician-administered balanced-sedation for the endoscopic mucosal resection of large non-pedunculated colorectal polyps

Sunil Gupta 
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
,
Rajiv Kurup 
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
,
Neal Shahidi
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
3   Gastroenterology and Hepatology, The University of British Columbia Faculty of Medicine, Vancouver, Canada (Ringgold ID: RIN12358)
,
Sergei Vosko 
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
,
Owen McKay 
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
,
Simmi Zahid
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
,
Anthony Whitfield
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
,
Eric Y. Lee
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
,
Stephen John Williams
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
,
Nicholas Graeme Burgess 
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
,
Michael J. Bourke
1   Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia (Ringgold ID: RIN8539)
2   Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia (Ringgold ID: RIN216997)
› Author Affiliations TRIAL REGISTRATION: Registration number (trial ID): NCT01368289, Trial registry: Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/), Type of Study: Retrospective AND Registration number (trial ID): NCT02000141, Trial registry: Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/), Type of Study: Retrospective
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Abstract

Background and study aims Because of concerns about peri-procedural adverse events (AEs), guidelines recommend anesthetist-managed sedation (AMS) for long and complex endoscopic procedures. The safety and efficacy of physician-administered balanced sedation (PA-BS) for endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm is unknown.

Patients and methods We compared PA-BS with AMS in a retrospective study of prospectively collected data from consecutive patients referred for management of LNPCPs (NCT01368289; NCT02000141). A per-patient propensity analysis was performed following a 1:2 nearest-neighbor (Greedy-type) match, based on age, gender, Charlson comorbidity index, and lesion size. The primary outcome was any peri-procedural AE, which included hypotension, hypertension, tachycardia, bradycardia, hypoxia, and new arrhythmia. Secondary outcomes were unplanned admissions, 28-day re-presentation, technical success, and recurrence.

Results Between January 2016 and June 2020, 700 patients underwent EMR for LNPCPs, of whom 638 received PA-BS. Among them, the median age was 70 years (interquartile range [IQR] 62–76 years), size 35 mm (IQR 25–45 mm), and duration 35 minutes (IQR 25–60 minutes). Peri-procedural AEs occurred in 149 (23.4%), most commonly bradycardia (116; 18.2%). Only five (0.8%) required an unplanned sedation-related admission due to AEs (2 hypotension, 1 arrhythmia, 1 bradycardia, 1 hypoxia), with a median inpatient stay of 1 day (IQR 1–3 days). After propensity-score matching, there were no differences between PA-BS and AMS in peri-procedural AEs, unplanned admissions, 28-day re-presentation rates, technical success or recurrence.

Conclusions Physician-administered balanced sedation for the EMR of LNPCPs is safe. Peri-procedural AEs are infrequent, transient, rarely require admission (<1%), and are experienced in similar frequencies to those receiving anesthetist-managed sedation.

Keywords

Sedation and monitoring - Quality and logistical aspects - Performance and complications


Publication History

Received: 24 December 2022

Accepted after revision: 17 August 2023

Accepted Manuscript online:
25 September 2023

Article published online:
05 January 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Vargo JJ, Cohen LB, Rex DK. et al. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc 2009; 70: 1053-1059
    CrossrefPubMedSearch in Google Scholar
  • 2 Sethi S, Wadhwa V, Thaker A. et al. Propofol versus traditional sedative agents for advanced endoscopic procedures: A meta-analysis. Dig Endosc 2014; 26: 515-524
    CrossrefPubMedSearch in Google Scholar
  • 3 Lapidus A, Gralnek IM, Suissa A. et al. Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2019; 32: 303
    PubMedSearch in Google Scholar
  • 4 Bahin FF, Heitman SJ, Rasouli KN. et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67: 1965-1973
    CrossrefPubMedSearch in Google Scholar
  • 5 Ahlenstiel G, Hourigan LF, Brown G. et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676
    CrossrefPubMedSearch in Google Scholar
  • 6 Jayanna M, Burgess NG, Singh R. et al. Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. J Clin Gastroenterol Hepatol 2016; 14: 271-278
    CrossrefPubMedSearch in Google Scholar
  • 7 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158: 1095-1129
    CrossrefPubMedSearch in Google Scholar
  • 8 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2017; 49: 270-297
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Jessica XY, Lin JL, Oliver M. et al. Trends in EMR for nonmalignant colorectal polyps in the United States. Gastrointest Endosc 2020; 91: 124-131
    CrossrefPubMedSearch in Google Scholar
  • 10 Shahidi N, Vosko S, Gupta S. et al. Previously attempted large nonpedunculated colorectal polyps are effectively managed by endoscopic mucosal resection. Am J Gastroenterol 2021; 116: 958-966
    CrossrefPubMedSearch in Google Scholar
  • 11 Shahidi N, Sidhu M, Vosko S. et al. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69: 673-680
    CrossrefPubMedSearch in Google Scholar
  • 12 Vosko S, Gupta S, Shahidi N. et al. Impact of technical innovations in endoscopic mucosal resection in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 95: 959-968
    CrossrefPubMedSearch in Google Scholar
  • 13 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017; 66: 1779-1789
    CrossrefPubMedSearch in Google Scholar
  • 14 Holt BA, Jayasekeran V, Sonson R. et al. Topical submucosal chromoendoscopy defines the level of resection in colonic EMR and may improve procedural safety (with video). Gastrointest Endosc 2013; 77: 949-953
    CrossrefPubMedSearch in Google Scholar
  • 15 Klein A, Tate DJ, Jayasekeran V. et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 2019; 156: 604-613
    CrossrefPubMedSearch in Google Scholar
  • 16 Tate DJ, Bahin FF, Desomer L. et al. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions. Endoscopy 2018; 41: 52-62
    PubMedSearch in Google Scholar
  • 17 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573-577
    CrossrefPubMedSearch in Google Scholar
  • 18 Klein A, Bourke MJ. How to perform high-quality endoscopic mucosal resection during colonoscopy. Gastroenterology 2017; 152: 466-471
    CrossrefPubMedSearch in Google Scholar
  • 19 Moss A, Bourke MJ, Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918
    CrossrefPubMedSearch in Google Scholar
  • 20 Jideh B, Bourke MJ. How to perform wide-field endoscopic mucosal resection and follow-up examinations. Gastrointest Endosc Clin N Am 2019; 29: 629-646
    CrossrefPubMedSearch in Google Scholar
  • 21 Klein A, Bourke MJ. Advanced polypectomy and resection techniques. Gastrointest Endosc Clin N Am 2015; 25: 303-333
    CrossrefPubMedSearch in Google Scholar
  • 22 Bourke MJ, Bhandari P. How I remove polyps larger than 20 mm. Gastrointest Endosc 2019; 90: 877-880
    CrossrefPubMedSearch in Google Scholar
  • 23 Ching H-L, Lau MS, Azmy IA. et al. Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54: 712-722
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Gupta S, Sidhu M, Shahidi N. et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7: 152-160
    CrossrefPubMedSearch in Google Scholar
  • 25 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
    Search in Google Scholar
  • 26 R Core Team. R: A language and environment for statistical computing. In. Vienna, Austria: R Foundation for Statistical Computing. https://www.r-project.org/ 2013
    PubMedSearch in Google Scholar
  • 27 Inadomi JM, Gunnarsson CL, Rizzo JA. et al. Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010; 72: 580-586
    CrossrefPubMedSearch in Google Scholar
  • 28 Nathan J, Klein A, Gralnek I. et al. Endoscopist-directed balanced propofol sedation is safe and effective in patients undergoing outpatient colonoscopy. Dig Endosc 2015; 6: 158-162
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Dumonceau J-M, Riphaus A, Schreiber F. et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy nurses and associates guideline–updated June 2015. Endoscopy 2015; 47: 1175-1189
    Thieme ConnectPubMedSearch in Google Scholar
  • 30 Lichtenstein D, Jagannath S, Baron T. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy Guidelines. Gastrointest Endosc 2008; 68: 815-826
    CrossrefPubMedSearch in Google Scholar
  • 31 Aronson WL, McAuliffe MS, Miller K. Variability in the American Society of Anesthesiologists physical status classification scale. AANA J 2003; 71: 265-276
    PubMedSearch in Google Scholar
  • 32 Sankar A, Johnson S, Beattie W. et al. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth 2014; 113: 424-432
    CrossrefPubMedSearch in Google Scholar
  • 33 Goldstein A, Keats AS. The risk of anesthesia. Anesthesiology 1970; 33: 130-143
    CrossrefPubMedSearch in Google Scholar
  • 34 Lee CK, Lee S-H, Chung I-K. et al. Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest Endosc 2011; 73: 206-214
    CrossrefPubMedSearch in Google Scholar