Endoscopic sedation and monitoring practice in Germany: re-evaluation from the first nationwide survey 3 years after the implementation of an evidence and consent based national guideline.

BACKGROUND AND STUDY AIMS: The use of sedation (e. g., of short-acting propofol) for gastrointestinal endoscopy has shown an upward trend in the USA and Europe over the last decade. To improve patient's safety different nationwide guidelines have been developed. This survey aimed at providing nationwide re-evaluated data 3 years after the implementation of consent- and evidence-based national guideline on sedation for gastrointestinal endoscopy. METHODS: A 24-item survey regarding current practices of endoscopy, sedation and monitoring in gastrointestinal endoscopy was sent to 4 405 members of the German Society of Digestive and Metabolic Diseases (DGVS). RESULTS: A total of 741/4405 (17 %) questionnaires were returned. Compared to 2007 we documented a further increase of the use of sedation during the performance of esophagogastro-duodenoscopies (EGDs) (82 vs. 74 % in 2007) and colonoscopies (91 vs. 87 % in 2007), accompanied with an increased rate of using propofol as a sedative agent in 97 vs. 74 % of the cases in 2007. In contrast the use of midazolam substantially decreased to 69 % versus 82 % in 2007. Most commonly used sedation regimens are still propofol ± benzodiazepines (43 vs. 38 % in 2007), while a combination of midazolam ± opioid decreased to 15 % versus 35 % in 2007. Unchanged to data from 2007, patients were routinely monitored by pulse oximetry (99 %). Routine use of an automated blood pressure monitoring increased to 40 % (versus 29 % in 2007) and the use of electrocardiography monitoring nearly doubled to 24 vs. 13 % in 2007. Supplemental oxygen is nowadays routinely administered in 64 % compared to 34 % of the cases in 2007. Regarding the administration of sedation we observed a profound increase of nurse-administered propofol sedation (NAPS; 73 % in 2011, 39 % in 2007) with a decrease of endoscopist-directed propofol sedation (29 % in 2011 vs. 59 % in 2007). However, monitored anaesthesia care was still only rarely used in Germany (2 %). CONCLUSION: After the implementation of the first national sedation guideline the use of propofol has become the most popular sedation regime in Germany, mainly administered as NAPS by trained nurses as a standard procedure. Automated blood pressure measurements and ECG recording were more often implemented in the monitoring practice and also the routine use of supplemental oxygen has been clearly improved.

Impact of S3 training courses "Sedation and Emergency Management in Endoscopy for Endoscopy Nurses and Assisting Personnel" on the process and structure quality in gastroenterological endoscopy in practices and clinics - results of a nationwide survey.

INTRODUCTION: After the S3 Guideline Sedation in Gastrointestinal Endoscopy was published, a training curriculum for a three-day course for endoscopy nurses was developed. The aim of this study was to investigate what effect the course participation had on the daily routine process and structure quality by implementing a German-wide survey in gastroenterology practices and clinics. METHODS: A questionnaire with a total of 44 individual questions on personnel, space, and equipment structure, sedation, peri- and post-interventional monitoring, as well as discharge and complication management in endoscopy departments was sent to a total of 2113 course participants (1056 Institutions). They had completed the seminar between December 2008/January 2009 and June 2010. RESULTS: The response rate was 21.2 % (224 /1056). Fifty-four percent were from clinic endoscopy departments, 46 % from practices. Overall, some form of structural change occurred in 86.8 % of the clinics and in 84.5 % of the practices. New staff was hired in 28.1 % of the clinics and 12.6 % of the practices. Rosters were changed in 11.6 % of the clinics and 7.8 % of the practices. Almost all issues improved after course participation. However, they did not reach statistic significance with the exception of the availability of peri-interventional ECG-monitoring in practices. The "performance of sedation in threesomes" increased in clinics by more than 20 % and in practices by more than 15 %. The use of the ASA-classification to assess risk increased significantly in clinics (before 24 %, after 50 %) as well as practices (before 40 %, after 60 %) by more than 20 % (p = 0.0007 and p = 0.0385, respectively). The documentation of the discharge status (e. g. using checklists) more than doubled in clinics (before 19 %, after 41.3 %) and practices (before 17.5 %, after 38.8 %) after course completion. CONCLUSION: The only nationwide endoscopy nurses' survey on structure and process quality in endoscopy so far, shows that since the publication of the S3 guideline in 2008 numerous processes and structures have improved with respect to patient safety.

Magnetic resonance cholangiopancreatography (MRCP) for suspected bilio-pancreatic disease: should the endoscopist take a second look?

INTRODUCTION: MRCP enables a planar ductography of the pancreatobiliary system, which for diagnostic purposes may render ERCP unnecessary. However, the interpretation of MRCP findings is primarily performed by radiologists, and it is unclear whether additional interpretation of the MRCP results by the endoscopist alters clinical management. PATIENTS AND METHODS: One-hundred and fifty-five consecutive patients, who were referred for further endoscopic procedures (EUS/ERCP) based on MRCP findings (performed within 4 weeks prior to admittance; a written radiological report as well as the digital images were available) were enrolled. Before the endoscopic examinations were done, the MRCP images were re-evaluated by an experienced endoscopist who was in charge of the further endoscopic management. The interpretations of the MRCP images by the radiologist and the endoscopist were then compared with the final diagnosis after the further endoscopic evaluation. Additionally, the recommendations made by the endoscopist for further patient management before and after MRCP image analysis were evaluated. RESULTS: The MRCP image quality was judged sufficient by the endoscopist in the majority of the cases (80 %).The diagnostic accuracy of the MRCP findings was 73 % based on the interpretation by the radiologist and 86 % from the interpretation of the endoscopist. In 14 patients the endoscopist scheduled an EUS instead of an ERCP after he had viewed the MRCP images. Overall, the endoscopic work-flow was modified by the additional interpretation of the MRCP by the endoscopist in 25/155 (16 %) of the cases. LIMITATIONS: This is a non-randomized, unblinded single-observer assessment. CONCLUSION: MRCP images should be additionally interpreted by an endoscopist before further endoscopic procedures are scheduled.

[Short version S3 guideline sedation for gastrointestinal endoscopy und medicolegal implications]. / S3-Leitlinie Sedierung in der gastrointestinalen Endoskopie: Kurzfassung apparativer, personeller und struktureller Voraussetzungen und juristische Implikationen bei der Umsetzung.

With the publication of the first German S3 guideline on sedation for gastrointestinal endoscopy, the topic sedation has recently attracted the interest not only of physicians and medical assistants but also of the general public. It remains the topic of many, often controversial, discussions. This discussion arises mainly because of the fact that with the guideline - although giving a structured survey of the already existing requirements on structural as well as personnel qualifications - more emphasis is placed on the necessary personnel resources, standards for adequate patient information on the sedation, and risk stratification for the patient with the publication of the guideline.

European Society of Gastrointestinal Endoscopy (ESGE) Guideline Development Policy.

Numerous scientific publications explore the field of gastrointestinal (GI) endoscopy (a Pubmed search currently yields > 73000 results). Therefore, guidelines have become an indispensable tool for incorporating up-to-date knowledge into daily clinical care. Since the 1990 s, the issuing of guidelines has been a central task of the European Society of Gastrointestinal Endoscopy (ESGE). Here, the ESGE clarifies the types of policy documents that it issues and the methodology used to produce them, taking into account recent methodological developments.

Biliary stents: models and methods for endoscopic stenting.

Biliary stenting is widely used to palliate malignant obstruction or to treat benign biliary diseases. Recently, the most important changes have related to self-expandable metal stents (SEMSs), which are now available in a wide variety of designs, and to treatment techniques. This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic biliary stenting: a technology review describes the stent models and stenting techniques, and a separate clinical guideline states the evidence and recommendations regarding stenting.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.

Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey.

BACKGROUND AND AIMS: The use of sedation (e. g., of short-acting propofol) for gastrointestinal endoscopy has shown an upward trend in the United States and Europe over the last decade. This survey aimed at providing nationwide data on the current practice of endoscopic sedation and monitoring in Germany. METHODS: A 21-item survey regarding current practices of endoscopy, sedation and monitoring in gastrointestinal endoscopy was sent to 3 802 members of the German Society of Digestive and Metabolic Diseases (DGVS). RESULTS: A total of 1 061 / 3 802 (28%) questionnaires were returned. The respondents performed an average of 28 esophagogastro-duodenoscopies (EGDs) and 25 colonoscopies per week. Endoscopic procedures were staged in a hospital setting (60%) more often than in private practices (40%). The majority of the EGDs (74%) and colonoscopies (87%) were carried out under sedation, however, this fact may be influenced by a recall bias. The most frequently used agents for sedation were midazolam in 82% and propofol in 74% of the cases. The most common sedation regimens applied were propofol plus benzodiazepines (38%) and benzodiazepines with an opioid (35%). Patients were routinely monitored by pulse oximetry (97%), automated blood pressure readings (29%) and/or electrocardiography (13%). Supplemental oxygen was routinely administered in 34% of them. Endoscopists' satisfaction with sedation was greater among those using propofol than in the group applying benzodiazepines (visual analogue scale, 8.8 +/- 0.9 vs. 8.2 +/- 1.3, p < 0.0001). CONCLUSION: Besides the common administration of short-acting benzodiazepines, sedation with propofol is also gaining ground in Germany; it is applied mainly in low doses (up to 150 mg). German endoscopists are highly satisfied with these sedation regimens, with propofol significantly leading the score. Patient monitoring predominantly follows currently prevailing guidelines.

Capsule endoscopy interpretation by an endoscopy nurse - a comparative trial.

BACKGROUND: Capsule endoscopy is a common, pain-free diagnostic procedure for the small bowel. However, interpretation of the whole video recording is a time-consuming and costly procedure that can take up to 2 hours. The aim of the present study is two-fold: first to study the accuracy of capsule endoscopy analysis between a trained endoscopy nurse and a physician and secondly to determine if pre-evaluation by nursing staff might be time-effective for capsule reading. This study is especially important given the increasing financial pressure on current health-care systems. METHODS: A long-standing experienced endoscopy nurse, who was trained to read capsule endoscopy, and a physician, both blinded to the patient diagnosis and the other clinical findings reviewed 48 consecutive capsule endoscopy videos. The analyses of both the nurse and the physician were re-evaluated by an independent doctor regarding the agreement of the marked findings. RESULTS: Total time to read capsule endoscopy was significantly longer for the nurse's interpretation (63 +/- 26 min) as compared to the physician's interpretation (54 +/- 18 min, p < 0.01). The endoscopy nurse marked 236 thumbnails, whereas the doctor only marked 132 thumbnails. The nurse overlooked 4 of 64 relevant lesions (6 %), which had been detected by the physician. These overlooked lesions were not single important lesions, they were overlooked only in patients with multiple angiectasias of the small intestine, and thus the misdiagnosis was without clinical relevance. The physician overlooked 6 of 68 lesions detected by the nurse (9 %), also in patients with multiple angiodysplastic lesions and therefore without clinical relevance. On post-hoc analysis of the capsule video recordings the time needed by the physician to interpret the thumbnails marked by the nurse was 10 +/- 12 min. While there was no difference with respect to the estimated gastric emptying time (nurse 27 +/- 13 min vs. physician 28 +/- 14 min, n. s.), the estimated time of capsule passage through the ileocaecal valve was longer when interpreted by the endoscopy nurse (nurse 347 +/- 89 min vs. physician 326 +/- 74 min, n. s.). Nevertheless, the total cost for capsule pre-evaluation by the nurse was lower (13.23 euro vs. physician 17.82 euro). CONCLUSION: The endoscopy nurse detected 94 % of the significant lesions seen by the physician and no clinically relevant findings were overlooked. A pre-evaluation of the capsule video by trained staff is an accurate method and might be time effective.

Catheter probe extraductal ultrasonography vs. conventional endoscopic ultrasonography for detection of bile duct stones.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) has been established as a valuable diagnostic tool for the detection of bile duct stones (BDS). The recently introduced extraductal endoscopic ultrasonography (EDUS) using miniprobes has the advantage that it can be performed with a duodenoscope, and if therapeutic interventions become necessary, there is no need to change the scope. PATIENTS AND METHODS: Consecutive patients with acute biliary pain and a dilated bile duct and/or elevated liver function tests, in whom the origin of biliary obstruction could not be identified by US and CT, were enrolled. The patients were investigated with a linear-array echoendoscope, and an additional transduodenal EDUS examination was performed with a 12-MHz miniprobe via the instrumentation channel of the echoendoscope. The presence or absence of BDS was afterwards evaluated by endoscopic retrograde cholangiopancreatography (ERCP)/sphincterotomy (EST) and by instrumental bile duct exploration (in the case of a positive EUS/EDUS finding), or by magnetic resonance cholangiopancreatography (MRCP) and ERCP with additional clinical follow-up (in the case of negative findings on EUS/EDUS). RESULTS: One hundred and fifty-five patients (55 +/- 12 years old, 98 female) were enrolled. In six cases, the distal bile duct could not be successfully visualized by EDUS, whereas with EUS visualization failed in only one patient ( P = 0.13). Choledocholithiasis was proven in 75 cases (48 %). The diagnostic accuracy of EUS for the detection of BDS (sensitivity 92 %, specificity 100 %, PPV 1.0, NPV 0.93, accuracy 95 %) was comparable to that of EDUS (sensitivity 90 %, specificity 98 %, PPV 0.99, NPV 0.93, accuracy 91 %, P = 0.17 vs. EUS). CONCLUSIONS: In patients at intermediate risk of BDS it seems to be justified to perform EDUS instead of EUS, and to proceed with ERCP and EST immediately when findings are positive.