Unsedated small-caliber esophagogastroduodenoscopy (EGD): less expensive and less time-consuming than conventional EGD.

BACKGROUND: A significant portion of the costs and complications of esophagogastroduodenoscopy (EGD) are related to the use of sedation. The feasibility and tolerability of small-caliber EGD (scEGD) without sedation has been evaluated; however, there is limited data concerning times and costs associated with this procedure as compared with conventional EGD (cEGD) with sedation. STUDY: Sixteen patients underwent scEGD with the Pentax EG-1840 (outside diameter, 6 mm) without sedation. A control group of 16 patients was matched for age, sex, day, and indication of procedure. The time of procedure, time in procedure room, time in recovery room, and procedure costs were determined in both the study and control groups. After the procedure, scEGD patients completed surveys consisting of visual-analogue scales to assess tolerance and preference regarding sedation for future procedures. RESULTS: Procedure time, procedure room time, and recovery room time was 5.2, 16.3, and 9 minutes for scEGD and 13.5, 34.9, and 41.3 minutes for cEGD, respectively (p < 0.001 for all comparisons). The mean cost of scEGD, excluding physician fees, was $462.00, which was significantly lower than the $587.00 for cEGD (p < 0.001). Survey results revealed good tolerance for the unsedated procedure. CONCLUSIONS: Unsedated scEGD was well tolerated and resulted in a shorter time of procedure, less time spent in procedure room, reduced recovery room time, and lower costs as compared with cEGD with sedation.

Identification of patients with resectable pancreatic cancer: at what stage are we?

In a prospective evaluation of 58 consecutive patients referred for operation of a suspected pancreatic or peri-ampullary cancer, the accuracy of ultrafast magnetic resonance imaging (UMRI) in predicting the resectability of pancreatic tumors compared with alternative staging interventions was assessed. The staging methods included: 1) transcutaneous ultrasound (US) with color Doppler, 2) UMRI, including echoplanar sequences and breath-hold gadolinium-enhanced dual-phase three-dimensional magnetic resonance angiography (MRA), 3) rapid bolus dual-phase helical computed tomography (CT), 4) angiography of celiac and mesenteric arterial systems, including portal venous phase, and 5) endoscopic cholangiopancreatography (performed in jaundiced patients). Patients were evaluated for extrapancreatic tumor spread, presence of hepatic metastases, lymph node involvement, and vascular involvement--each a sign of unresectability. After an investigator blinded to the results of the other imaging studies assessed resectability, patients were then divided into three categories: 1) probably resectable, 2) probably unresectable, and 3) certainly inoperable. Final diagnosis was obtained by laparotomy (47 of 58 pts), or by histopathological examination of fine needle aspiration specimens in patients deemed inoperable. The 58 suspected tumors were localized to the pancreatic head in 35 (60%), body in 11 (19%), and tail in one (2%). Nine (16%) ampullary tumors and two (3%) distal common bile duct tumors made up the remainder. For those 52 patients for whom histology was obtained, 44 were malignant and eight benign. Accuracy for assessing extrapancreatic tumor extension was highest with UMRI (95.7%) followed by US (85.1%), and CT (74.4%). UMRI provided the best means for detecting liver metastases with an accuracy of 93.5% compared with 87.2% for each of US and CT. UMRI, US, and CT had a reduced capacity for detecting lymph node involvement (80.4%, 76.6%, and 69.2%, respectively). In assessing vascular invasion, UMRI had an accuracy of 89.1%, US 83.0%, CT 79.5%, and angiography 68.8%. The findings suggest that UMRI is equal to or superior to other staging methods with regards to sensitivity, specificity, and overall accuracy. Since UMRI has the potential to reduce patient time, money, and discomfort, this study concludes that this staging technique should replace alternative methods as it provides an "all-in-one" diagnostic modality.

Differential effects of amitriptyline on perception of somatic and visceral stimulation in healthy humans.

Tricyclic antidepressants treat chronic pain both in patients with somatic illness and with functional bowel disorders. We compared the effects of amitriptyline on perception of cutaneous and gastrointestinal stimulation to assess differential analgesic effects of tricyclics on somatic and visceral pain. Cutaneous electrical stimulation and rectal and esophageal distension were performed before and after 21 days of double-blind 50 mg amitriptyline vs. placebo in healthy volunteers. Amitriptyline increased currents that elicited cutaneous threshold, moderate discomfort, and moderate pain compared with basal (P < 0.05), whereas placebo had no effect. Amitriptyline had no effect on perception of rectal and esophageal distension and did not alter luminal compliance; thus the lack of effect on perception is not due to altered visceral elastic wall properties. In conclusion, amitriptyline reduces perception of cutaneous stimulation but does not alter visceral perception or compliance. This investigation demonstrates differential effects of tricyclics on somatic and visceral afferent function in healthy humans and provides insight into mechanisms of action in chronic pain both from somatic disease and from functional bowel disorders.