Correspondence
Endoscopy
N Engl J Med 2000; 342:1219-1221April 20, 2000
- Article
To the Editor:
In their otherwise excellent review of endoscopy of the upper gastrointestinal tract, Drs. Van Dam and Brugge (Dec. 2 issue)1 start with a discussion of the likely economic benefits of performing upper gastrointestinal endoscopy without using sedation. They appear to imply that this practice would be acceptable only with the use of “ultrathin” flexible endoscopes (6 mm in diameter).
In the United Kingdom, the practice of performing diagnostic upper gastrointestinal endoscopy without sedation in selected patients has become more common over the past few years, even with conventional 9-to-11-mm endoscopes. Thus, although a 1991 British Society of Gastroenterology study of practice in the United Kingdom showed that only about 10 percent of diagnostic upper gastrointestinal endoscopies were performed without the use of sedation, the results of a 1998 study of a large center in the United Kingdom, which showed that about 65 percent of such procedures were performed without sedation, are probably more representative of present-day practice.2
This alteration in practice has been brought about in part by increasing pressures because of waiting lists for endoscopy and constraints on the use of facilities for post-procedure recovery, but also by the growing realization that endoscopy without sedation, with the use of conventional instruments, is fully acceptable to many patients (and indeed some prefer it to endoscopy with sedation).3,4 Thus, the current guidelines of the British Society of Gastroenterology state that patients “should be offered the choice to have sedation or not” for diagnostic upper gastrointestinal endoscopy.5 Those who decline sedation have the advantage of being able to engage in a meaningful conversation with the clinician immediately after the procedure and then being able to return to work.
5 ReferencesNeil C. Fisher, M.D.
Dudley Group of Hospitals, West Midlands DY8 5QX, United Kingdom1
Van Dam J ,Brugge WR . Endoscopy of the upper gastrointestinal tract. N Engl J Med 1999;341:1738-1748
Full Text | Web of Science | Medline2
Connor P ,Mulcahy HE ,Rhodes B ,Patchett SE ,Farthing MJG ,Fairclough PD . Declining use of sedation for routine diagnostic upper GI endoscopy. Gut 1999;44:Suppl 1:A17-A17 abstract.
CrossRef | Web of Science3
Fisher NC ,Bailey S ,Gibson JA . A prospective, randomized controlled trial of sedation vs. no sedation in outpatient diagnostic upper gastrointestinal endoscopy. Endoscopy 1998;30:21-24
CrossRef | Web of Science | Medline4
Tan CC ,Freeman JG . Throat spray for upper gastrointestinal endoscopy is quite acceptable to patients. Endoscopy 1996;28:277-282
CrossRef | Web of Science | Medline5
British Society of Gastroenterology. Guidelines for informed consent for endoscopic procedures. Guidelines in Gastroenterology. Vol. 11. 1999.
To the Editor:
In their review of pancreatic and biliary endoscopy, Drs. Brugge and Van Dam (Dec. 9 issue)1 discuss the use of metal stents for the palliation of unresectable cholangiocarcinomas and gallbladder cancer. They state, “Although metal stents can be placed transhepatically, the endoscopic approach is preferred, because of its lower cost and ease of use.” In defense of this position, they cite a report by Raikar et al.,2 who compared the cost effectiveness of surgical palliation with that of endoscopic stent placement. However, these investigators compared 34 patients who underwent endoscopic stent placement with 32 patients who underwent surgical bypass procedures; no patients received transhepatic stents.
Transhepatic stents are placed by interventional radiologists in the radiology department, not in the operating room. An experienced interventional radiologist can place these stents rather easily; in many cases, transhepatic placement is easier than endoscopic placement. I performed a literature search and found no studies comparing the cost effectiveness of transhepatic stent placement with that of endoscopic stent placement. The lower-cost-and-ease-of-use argument does not hold up. The less invasive nature of endoscopic stent placement, as compared with transhepatic placement, is its predominant merit. Transhepatic placement is thus reserved for patients who cannot be treated endoscopically.
2 ReferencesSamuel G. Putnam, M.D.
Pennsylvania Hospital, Philadelphia, PA 191071
Brugge WR ,Van Dam J . Pancreatic and biliary endoscopy. N Engl J Med 1999;341:1808-1816
Full Text | Web of Science | Medline2
Raikar GV ,Melin MM ,Ress A , et al. Cost-effective analysis of surgical palliation versus endoscopic stenting in the management of unresectable pancreatic cancer. Ann Surg Oncol 1996;3:470-475
CrossRef | Web of Science | Medline
To the Editor:
Brugge and Van Dam comprehensively review the progress in pancreatic and biliary endoscopy.1 Unfortunately, in cases of pancreatic or extrahepatic biliary cancer, the authors' conclusions are misleading, and they fail to recommend precisely when endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography is indicated — or better, when these procedures are not indicated.
In patients with painless jaundice in whom a pancreatic or other periampullary cancer is suspected, high-resolution abdominal computed tomography (CT) with the administration of contrast material should be performed, with fine cuts through the pancreas. If a mass is identified without evidence of metastatic disease or vascular encasement, and if there is no clinical evidence of cholangitis, surgical resection should be considered, without the need for stent placement or biopsy.2
In patients undergoing pancreatoduodenectomy, preoperative biliary stent decompression has been linked to significantly increased rates of morbidity and mortality from infection.3 Since approximately two thirds of patients in whom resection is performed have undergone unnecessary preoperative ERCP or biopsy attempts, a reduction in morbidity and cost savings appear to be feasible if these procedures are avoided.4 Diagnostic laparoscopy at the beginning of a planned operation is the preferred complement to CT scanning, since serosal or small visceral metastatic tumors can be identified with this approach.1,2 If delineation of the biliary system is important for operative planning, magnetic resonance cholangiography has been shown to be similar or superior to ERCP for this purpose.5
Consequently, one would have to recommend the avoidance of diagnostic endoscopic manipulations of biliary or pancreatic ducts in patients with jaundice who have potentially resectable pancreatic or other periampullary masses, until possibly curative treatment options have been evaluated by a surgeon with the appropriate expertise. It can be expected that the majority of patients with pancreatic cancer will present with unresectable disease and will still benefit from endoscopic procedures such as stent placement or biopsy.
5 ReferencesRoderich E. Schwarz, M.D.
City of Hope National Cancer Center, Duarte, CA 910101
Brugge WR ,Van Dam J . Pancreatic and biliary endoscopy. N Engl J Med 1999;341:1808-1816
Full Text | Web of Science | Medline2
NCCN practice guidelines for pancreatic cancer. Oncology (Huntingt) 1997;11:41-55
Medline3
Povoski SP ,Karpeh MS Jr ,Conlon KC ,Blumgart LH ,Brennan MF . Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999;230:131-142
CrossRef | Web of Science | Medline4
Schwarz RE ,Keny H ,Ellenhorn JD . A mortality-free decade of pancreatoduodenectomy: is quality independent of quantity? Am Surg 1999;65:949-954
Web of Science | Medline5
Georgopoulos SK ,Schwartz LH ,Jarnagin WR , et al. Comparison of magnetic resonance and endoscopic retrograde cholangiopancreatography in malignant pancreaticobiliary obstruction. Arch Surg 1999;134:1002-1007
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Fisher comments on the use of endoscopy without sedation in the United Kingdom. The approach to upper gastrointestinal endoscopy, particularly in the use of sedative and analgesic medications, varies widely throughout the world.1 These differences reflect the availability of the agents, the prevailing opinions of endoscopists with respect to their use, and cultural differences. Although benzodiazepines are generally preferred for sedation in the United States, the benefit of premedication for esophagogastroduodenoscopy remains controversial. More than 30 percent of patients who were invited to participate in a trial of endoscopy with the use of an ultrathin endoscope and no sedation refused, in most cases because of anxiety and fear of gagging.2 Although we agree that patients should be offered a choice, American patients appear to be less willing than patients in other parts of the world to undergo endoscopy without sedation.
We agree with Dr. Putnam that “the less invasive nature of endoscopic stent placement, as compared with transhepatic placement, is its predominant merit.” Transhepatic stent placement is usually attempted after transhepatic cholangiography and external biliary drainage. In one study, patients undergoing these procedures were hospitalized for an average of 11 days.3 In contrast, ERCP with stent placement is usually performed as a single outpatient procedure.4 Although we were unable to provide a citation for the lower cost of endoscopic biliary stent placement, we think Dr. Putnam would agree that the less invasive and simpler method of stent placement is preferable and that transhepatic stent placement should be reserved for patients who cannot be treated endoscopically.
We agree with Dr. Schwarz that ERCP and endoscopic ultrasonography are not indicated in all patients with painless obstructive jaundice and that spiral CT scanning can be performed to determine the potential for resectability in many cases. ERCP and endoscopic ultrasonography should be reserved for cases in which the cause of the obstruction is not clearly identified by CT scanning and for cases in which a palliative approach is sought by the patient or the physician. In the study by Georgopoulos et al., cited by Dr. Schwarz, magnetic resonance cholangiopancreatography was used to determine the level of biliary obstruction in 87 percent of the patients. However, with the use of ERCP and endoscopic ultrasonography, the advantages include not only high-quality images but also a tissue diagnosis, biliary stenting, and the opportunity to relieve pain with a celiac-ganglion blockade. We agree that laparoscopy can be used before surgical resection and will detect occult metastatic disease in 29 percent of patients.5
5 ReferencesJacques Van Dam, M.D., Ph.D.
William R. Brugge, M.D.
Harvard Medical School, Boston, MA 021151
Van Dam J, Chak A, Sivak MV Jr. Technique of upper gastrointestinal endoscopy. In: Sivak MV Jr, ed. Gastroenterologic endoscopy. Philadelphia: W.B. Saunders, 2000:458-64.
2
Zaman A ,Hapke R ,Sahagun G ,Katon RM . Unsedated peroral endoscopy with a video ultrathin endoscope: patient acceptance, tolerance, and diagnostic accuracy. Am J Gastroenterol 1998;93:1260-1263
CrossRef | Web of Science | Medline3
Lee MJ ,Dawson SL ,Mueller PR ,Krebs TL ,Saini S ,Hahn PF . Palliation of malignant bile duct obstruction with metallic biliary endoprostheses: technique, results, and complications. J Vasc Interv Radiol 1992;3:665-671
CrossRef | Medline4
Tham TC ,Vandervoort J ,Wong RC , et al. Therapeutic ERCP in outpatients. Gastrointest Endosc 1997;45:225-230
CrossRef | Web of Science | Medline5
Reddy KR ,Levi J ,Livingstone A , et al. Experience with staging laparoscopy in pancreatic malignancy. Gastrointest Endosc 1999;49:498-503
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Sanjoy Basu, Badri Krishnamurthy, Tim H. Walsh. (2004) Value of Fentanyl in Flexible Sigmoidoscopy. World Journal of Surgery 28:9, 930-934
CrossRef
