Etomidate Combined with Propofol versus Remimazolam for Sedation in Elderly Patients During Gastrointestinal Endoscopy: A Randomized Prospective Clinical Trial.

Purpose: Remimazolam is a novel short-acting benzodiazepine used for sedation and general anesthesia. This study aimed to evaluate the efficacy and safety of remimazolam besylate in elderly patients who underwent diagnostic gastrointestinal endoscopy. Patients and Methods: A total of 120 patients aged 60-75 years were randomly allocated to one of two groups. Remifentanil 0.3µg/kg was used for analgesia. Patients were administered remimazolam besylate 7 mg (R group) or etomidate 0.1 mg/kg combined with 1% propofol 0.5 mg/kg (EP group) for induction, supplemental repeated doses were given as needed. Some time metrics, vital signs, adverse events were evaluated. Patients' Mini-cog score and recovery questionnaires were compared. Results: Compared to the EP group, the induction time was slightly longer in the R group (1.50 VS 1.15 minutes) (P<0.05), the time spent in the post-anesthesia care unit (PACU) was shorter (15.17 VS 17.40 minutes) (P<0.05). Compare with EP group, SBP was lower in R group at T15 and T25 time point, but heart rate was higher in T2, T3, T5 (P< 0.05). The Mini-Cog score was higher after the procedure (2.83 VS 2.58) (P<0.05). The incidence of respiratory adverse events was higher in the EP group than R group (18.3% VS 5.0%, P < 0.05). The most common adverse event in R group was hiccups. The sedation satisfaction rate and degree of amnesia were higher in the R group (66.7% VS 11.7%) (P < 0.05), and the effect on patient's life within 24 hours was lower (12.0% VS 30.5%) (P < 0.05). Conclusion: The safety and efficacy of remimazolam besylate are not inferior to those of etomidate combined with propofol, rendering it a safe option for sedation during gastrointestinal endoscopy in ASA I-II elderly patients, but care should be taken to monitor the occurrence of hiccups.

Prospective multicenter study to identify optimal target population for motorized spiral enteroscopy.

Motorized spiral enteroscopy (MSE) enhances small bowel exploration, but the optimal target population for this technique is unknown. We aimed to identify the target population for MSE by evaluating its efficacy and safety, as well as detecting predictors of efficacy. A prospective multicenter observational study was conducted at 9 tertiary hospitals in Spain, enrolling patients between June 2020-2022. Analyzed data included demographics, indications for the procedure, exploration time, depth of maximum insertion (DMI), technical success, diagnostic yield, interventional yield, and adverse events (AE) up to 14 days from enteroscopy. Patients with prior gastrointestinal surgery, unsuccessful balloon enteroscopy and small bowel strictures were analyzed. A total of 326 enteroscopies (66.6% oral route) were performed in 294 patients (55.1% males, 65 years ± 21). Prior abdominal surgery was present in 50% of procedures (13.5% gastrointestinal surgery). Lower DMI (162 vs 275 cm, p = 0.037) and diagnostic yield (47.7 vs 67.5%, p = 0.016) were observed in patients with prior gastrointestinal surgery. MSE showed 92.2% technical success and 56.9% diagnostic yield after unsuccessful balloon enteroscopy (n = 51). In suspected small bowel strictures (n = 49), the finding was confirmed in 23 procedures (46.9%). The total AE rate was 10.7% (1.8% classified as major events) with no differences related to prior gastrointestinal/abdominal surgery, unsuccessful enteroscopy, or suspected small bowel strictures. The study demonstrates that MSE has a lower diagnostic yield and DMI in patients with prior gastrointestinal surgery but is feasible after unsuccessful balloon-enteroscopy and in suspected small bowel strictures without safety concerns.

[Pan American Crohn's and Colitis Organization (PANCCO) and the Interamerican Society of Endoscopy (SIED) consensus on endoscopy in inflammatory bowel disease]. / Consenso de endoscopia en enfermedad inflamatoria intestinal de la Organización Panamericana de Crohn y Colitis (PANCCO) y la Sociedad Interamericana de endoscopia (SIED).

INTRODUCTION: Endoscopy plays a fundamental role in inflammatory bowel disease (IBD), and becomes essential in diagnosis, treatment monitoring, and detection and management of complications. MATERIALS AND METHODS: The Pan American Crohn's and Colitis Organization (PANCCO) and the Inter-American Society of Endoscopy (SIED) appointed 22 Latin American experts in IBD to develop a consensus study using the modified Delphi method, based on the best available evidence. A working group of 22 members from 9 countries identified 15 topics and formulated 98 statements, who participated in 2 rounds of voting. It was defined as agreement of ≥80% of experts for each statement. RESULTS: After the voting of all the statements, 8 statements were obtained that did not reach 80% consensus among the participants, so the questions were reconsidered in the Coordinating Committee of the consensus with the participation of the expert reviewers of these questions and 7 final statements were voted again by all the experts in a second round and 1 was eliminated with consensus. After two rounds of voting, the experts reached consensus with literature review with the best available evidence, the most important issues were developed with scientific evidence supporting each of the statements around the topic of endoscopy in IBD. CONCLUSIONS: Consensus statements were developed and based on the best available evidence about endoscopy in inflammatory bowel disease.

Development and validation of a predictive model for PACU hypotension in elderly patients undergoing sedated gastrointestinal endoscopy.

BACKGROUND: Hypotension, characterized by abnormally low blood pressure, is a frequently observed adverse event in sedated gastrointestinal endoscopy procedures. Although the examination time is typically short, hypotension during and after gastroscopy procedures is frequently overlooked or remains undetected. This study aimed to construct a risk nomogram for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing sedated gastrointestinal endoscopy. METHODS: This study involved 2919 elderly patients who underwent sedated gastrointestinal endoscopy. A preoperative questionnaire was used to collect data on patient characteristics; intraoperative medication use and adverse events were also recorded. The primary objective of the study was to evaluate the risk of PACU hypotension in these patients. To achieve this, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection, involving cyclic coordinate descent with tenfold cross-validation. Subsequently, multivariable logistic regression analysis was applied to build a predictive model using the selected predictors from the LASSO regression. A nomogram was visually developed based on these variables. To validate the model, a calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used. Additionally, external validation was conducted to further assess the model's performance. RESULTS: The LASSO regression analysis identified predictors associated with an increased risk of adverse events during surgery: age, duration of preoperative water abstinence, intraoperative mean arterial pressure (MAP) <65 mmHg, decreased systolic blood pressure (SBP), and use of norepinephrine (NE). The constructed model based on these predictors demonstrated moderate predictive ability, with an area under the ROC curve of 0.710 in the training set and 0.778 in the validation set. The DCA indicated that the nomogram had clinical applicability when the risk threshold ranged between 20 and 82%, which was subsequently confirmed in the external validation with a range of 18-92%. CONCLUSION: Incorporating factors such as age, duration of preoperative water abstinence, intraoperative MAP <65 mmHg, decreased SBP, and use of NE in the risk nomogram increased its usefulness for predicting PACU hypotension risk in elderly patient undergoing sedated gastrointestinal endoscopy.

Fecal calprotectin and endoscopic scores: The cornerstones in clinical practice for evaluating mucosal healing in inflammatory bowel disease.

Managing inflammatory bowel disease (IBD) is becoming increasingly complex and personalized, considering the advent of new advanced therapies with distinct mechanisms of action. Achieving mucosal healing (MH) is a pivotal therapeutic goal in IBD management and can prevent IBD progression and reduce flares, hospitalization, surgery, intestinal damage, and colorectal cancer. Employing proactive disease and therapy assessment is essential to achieve better control of intestinal inflammation, even if subclinical, to alter the natural course of IBD. Periodic monitoring of fecal calprotectin (FC) levels and interval endoscopic evaluations are cornerstones for evaluating response/remission to advanced therapies targeting IBD, assessing MH, and detecting subclinical recurrence. Here, we comment on the article by Ishida et al Moreover, this editorial aimed to review the role of FC and endoscopic scores in predicting MH in patients with IBD. Furthermore, we intend to present some evidence on the role of these markers in future targets, such as histological and transmural healing. Additional prospective multicenter studies with a stricter MH criterion, standardized endoscopic and histopathological analyses, and virtual chromoscopy, potentially including artificial intelligence and other biomarkers, are desired.

Validation of the ViGaTu Immersive Virtual Reality Endoscopy Training System for Physicians and Nurses.

BACKGROUND AND AIMS: Endoscopy simulators are primarily designed to provide training in interventions performed during procedures. Peri-interventional tasks such as checking patient data, filling out forms for team time-out, patient monitoring, and performing sedation are often not covered. This study assesses the face, content, and construct validity of the ViGaTu (Virtual Gastro Tutor) immersive virtual reality (VR) simulator in teaching these skills. METHODS: 71 nurses and physicians were invited to take part in VR training. The participants experienced an immersive VR simulation of an endoscopy procedure, including setting up the endoscopic devices, checking sign-in and team time-out forms, placing monitoring devices, and performing sedation. The actions performed by the participants and their timing were continuously recorded. Face and content validity, as well as the System Usability Scale (SUS), were then assessed. RESULTS: 43 physicians and 28 nurses from 43 centers took a mean of 27.8 min (standard deviation ± 14.42 min) to complete the simulation. Seventy-five percent of the items for assessing face validity were rated as realistic, and 60% of items assessing content validity and usefulness of the simulation for different learning goals were rated as useful by the participants (four out of five on a Likert scale). The SUS score was 70, demonstrating a high degree of usability. With regard to construct validity, experienced endoscopy staff were significantly faster in setting up the endoscope tower and instruments than beginners. CONCLUSIONS: This multicenter study presents a new type of interdisciplinary endoscopy training system featuring peri-interventional tasks and sedation in an immersive VR environment.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices: Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies. Moreover, the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

[ADVANCES ON ESOPHAGEAL MEASUREMENTS: HIGH RESOLUTION MANOMETRY, TIMED BARIUM SWALLOW, ENDOFLIP AND PH MONITORING].

INTRODUCTION: Upper gastrointestinal (UGI) symptoms are very common in the general adult population. Dysphagia, heartburn, regurgitation and non-cardiac chest pain are the most common signs. The clinical approach in managing these symptoms starts with upper GI endoscopy in order to exclude inflammatory, neoplastic and fibrotic disorders that involve the esophagus. Upper GI endoscopy is mandatory especially when alarm signs exist. In patients with no structural abnormalities, physiological testing might aid to better understand the origin of the symptoms and to improve management.

Routine upper gastro-intestinal tract endoscopy before elective cholecystectomy for symptomatic gallstones-justified.

Gallstones are common in Western countries and increasing in developing countries through adoption of western lifestyle. Gallstones may cause life-threatening complications, including acute cholecystitis, acute cholangitis, and acute pancreatitis. Cholecystectomy is the treatment of choice for symptomatic gallstones. Presentation of symptomatic gallstones may be indistinguishable from that of other upper gastro-intestinal tract (UGI) pathologies. Some surgeons routinely perform preoperative UGI endoscopy to diagnose and treat concomitant UGI pathology. A prospective cross-sectional observational study was undertaken at University of Pretoria teaching hospitals to evaluate this practice. Patients aged 18 years and older, with symptomatic gallstones but did not satisfy Tokyo guidelines for acute cholecystitis were recruited. UGI endoscopy was performed before cholecystectomy. There were 124 patients, 110 (88.7%) females and 14 (11.3%) males, mean age 44.0 (13.2) (range: 22-78) years. Most common symptoms were right upper quadrant (RUQ) pain (87%), epigastric pain (59.7%), nausea (58.1%) and vomiting (47.9%). Clinically, 80% had RUQ tenderness and 52.4% epigastric tenderness. UGI endoscopy found 35.4% pathology, 28.2% were active, and comprised acute gastritis (27.4%), peptic ulcers (4.8%), duodenitis (3.2%) and oesophagitis (2.4%). Twelve patients had more than one pathology. This warranted treatment before elective cholecystectomy and justifies the practice of routine preoperative UGI endoscopy.

Influences of Propofol, Ciprofol and Remimazolam on Dreaming During Anesthesia for Gastrointestinal Endoscopy: A Randomized Double-Blind Parallel-Design Trial.

Purpose: To compare the influences of propofol, ciprofol and remimazolam on dreaming during painless gastrointestinal endoscopy. Methods: This study was a single-center, prospective, parallel-design, double-blind, randomized clinical trial. Between May 2023 and October 2023, patients undergoing elective painless gastrointestinal endoscopy were recruited and randomly allocated into one of the three groups. Demographic data, intraoperative information, incidence of dreaming, insufficient anesthesia and intraoperative awareness, type of dream, patient satisfaction score, adverse events, and improvement of sleep quality were collected. Results: The difference in incidence of dreaming among the three groups was not significant (33.33% vs 48.33% vs 41.67%, p=0.061). The number of patients with intraoperative hypotension in the propofol group was larger than that of the remimazolam group (32 vs 12, p=0.001). However, the cases of intraoperative hypotension between propofol group and ciprofol group or ciprofol group and remimazolam group were comparable (32 vs 22, p=0.122; 22 vs 12, p=0.064). The percentage of insufficient anesthesia between propofol group and remimazolam group was significant (13.33% vs 1.67%, p=0.001), while no statistical difference was detected between propofol group and remimazolam group or ciprofol group and remimazolam group (13.33% vs 5.00%, p=0.025; 5.00% vs 1.67%, p=0.150). The ability of propofol to improve sleep quality at 1st post-examination day was significantly better than that of remimazolam (86.21% vs 72.88%, p=0.015), while it was not significant between propofol group and ciprofol group or ciprofol group and remimazolam group (86.21% vs 80.36%, p=0.236; 72.88% vs. 72.88%, p=0.181). Incidence of intraoperative awareness, intraoperative hypoxia, type of dream, satisfaction score, adverse events during recovery, and sleep improvement on the 7th post-examination day was not significant among the groups. Conclusion: Anesthesia with propofol, ciprofol and remimazolam, respectively, for gastrointestinal endoscopy did not induce statistical difference in the incidence of dreaming, despite that all of them are more likely to induce pleasant dreams.

Gastrointestinal System Symptoms, Psychological Resilience, Emotional Self-Efficacy, and Healthy Living Behaviors in Patients Scheduled for Endoscopy/Colonoscopy.

Gastrointestinal symptoms are very common worldwide. This study aimed to examine the relationship between gastrointestinal system symptoms, psychological resilience, emotional self-efficacy, and healthy living behaviors in patients. The study was conducted in a training and research hospital in Türkiye with 258 patients who had experienced gastrointestinal symptoms and were scheduled for upper endoscopy and/or colonoscopy. The data were obtained by using an information form, the Brief Resilience Scale, the Emotional Self-Efficacy Scale, the Healthy Lifestyle Behaviors Scale, and the Gastrointestinal Symptom Rating Scale. A statistically positive and significant relationship was found between the Emotional Self-Efficacy Scale and the Healthy Lifestyle Behaviors Scale (r = 0.376; p < .05). It was determined that there was a statistically significant negative relationship between the mean Brief Resilience Scale and the Gastrointestinal Symptom Rating Scale scores (r = -0.150; p < .05). In addition, a positive and significant relationship was found between the mean Brief Resilience Scale and the Emotional Self-Efficacy Scale scores (r = 0.374; p < .05). Psychological factors and healthy living behaviors thus clearly affect gastrointestinal system symptoms. For this reason, it is thought that planning interventions to teach self-management through healthy living behaviors and promoting psychological resilience may reduce gastrointestinal system symptoms.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.