Cerebral oximetry monitoring in non-intubated patients undergoing endoscopic retrograde cholangiopancreatography under propofol-induced sedation: a prospective observational study.

BACKGROUND: Prolonged propofol-induced deep sedation increases the risk for sedation-related complications. Cerebral oximetry enables prompt assessment of tissue oxygenation by demonstrating the regional hemoglobin oxygen saturation (rSO2) of the cerebral cortex. This study aimed to: evaluate cerebral oxygenation under deep sedation during an endoscopic retrograde cholangiopancreatography (ERCP) procedure; determine the cerebral desaturation event (CDE) rate; and assess the predictive capacity of CDEs for sedation-related complications. METHODS: All consecutive patients who underwent ERCP between September and December 2019 were included prospectively. Propofol monotherapy was used and sedation level was assessed using the bispectral index (BIS). The target level of sedation was deep sedation, defined by BIS values 40-60. Participants were monitored with arterial blood gas analysis and INVOS 5100C cerebral oximeter. RSO2 values were registered prior to sedation (baseline value), every 5 min during the sedation period and at recovery of consciousness. BIS values were recorded simultaneously. CDE was defined as a drop >10% from individual baseline rSO2. RESULTS: Sixty patients were enrolled. Mean baseline rSO2 was 65.1% and BIS values ranged from 18-85. No significant correlation was observed between mean rSO2 measurements and mean BIS values throughout the recordings (P = 0.193). Data from patients aged ≥65 years were analyzed separately and the results were similar. The CDE rate was 2.7%, but no CDE was associated with clinical manifestations. Twelve sedation-related complications occurred without the presence of cerebral desaturation. CONCLUSION: Cerebral oxygenation remained independent of changes in sedation depth and cerebral oximetry monitoring did not detect complications earlier than standard monitors.

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: a randomized controlled trial.

BACKGROUND: Endoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy. AIMS: To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy. METHODS: A total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64). RESULTS: The complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group. CONCLUSIONS: 30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.

Deep sedation for endoscopic retrograde cholangiopacreatography.

Sedation and analgesia comprise an important element of unpleasant and often prolonged endoscopic retrograde cholangiopacreatography (ERCP), contributing, however, to better patient tolerance and compliance and to the reduction of injuries during the procedure due to inappropriate co-operation. Although most of the studies used a moderate level of sedation, the literature has revealed the superiority of deep sedation and general anesthesia in performing ERCP. The anesthesiologist's presence is mandatory in these cases. A moderate sedation level for ERCP seems to be adequate for octogenarians. The sedative agent of choice for sedation in ERCP seems to be propofol due to its fast distribution and fast elimination time without a cumulative effect after infusion, resulting in shorter recovery time. Its therapeutic spectrum, however, is much narrower and therefore careful monitoring is much more demanding in order to differentiate between moderate, deep sedation and general anesthesia. Apart from conventional monitoring, capnography and Bispectral index or Narcotrend monitoring of the level of sedation seem to be useful in titrating sedatives in ERCP.