Techniques in Gastrointestinal Endoscopy RSS feed: Current Issue. This addition to the Operative Techniques series presents each issue in an "operative report" approach that places a vigorous emphasis on diagnosis, rationale for and against a procedure, actual technique, management, and prevention of complications. The journal features abundant illustrations, line drawings and color artwork to guide readers through even the most complicated procedure. 2009 Topics , Vol. 11, Issues 1-4 January Interface of ERCP and EUS for Pancreaticobiliary Pathology Steve Edmundowicz April NOTES in Clincial Application Anthony Kalloo July Management of Pulmonary Complications of GI Disease Dan Sterman October Endoscopic Management of Esophageal Strictures Todd H. Baron http://www.techgiendoscopy.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Techniques in Gastrointestinal Endoscopy1096-2883114October 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.techgiendoscopy.com/article/PIIS1096288309000874/abstract?rss=yesCover10.1016/S1096-2883(09)00087-4Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7OFCOFChttp://www.techgiendoscopy.com/article/PIIS1096288309000886/abstract?rss=yesMasthead10.1016/S1096-2883(09)00088-6Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7IFCIFChttp://www.techgiendoscopy.com/article/PIIS1096288309000904/abstract?rss=yesEditorial Board10.1016/S1096-2883(09)00090-4Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7iihttp://www.techgiendoscopy.com/article/PIIS1096288309000916/abstract?rss=yesTable of Contents10.1016/S1096-2883(09)00091-6Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7iiiiiihttp://www.techgiendoscopy.com/article/PIIS1096288309000849/abstract?rss=yesThere is little question that the state of play in sedation for endoscopic procedures is in considerable flux. The epidemic of morbid obesity, the aging of the baby boom generation, and improved technology for early detection of colon and esophageal cancer have increased the volume and acuity of procedures as continuing pressure to contain costs have increased pressure to improve efficiency. Improvements in efficiency in procedural sedation can be significant, particularly in high-volume centers, but many anesthesia departments are inadequately staffed for out-of-operating room coverage, and trends in reimbursement portend a retreat from endoscopy by anesthesiologists. Battles over control of propofol have erupted. Clearly, this is hostile territory into which only brave scouts should tread. Despite this fear, there are those who have persevered and established expertise in safe conduct of new paradigms of sedation in endoscopy. The intent of this issue is to share some of this hard-won insight. There is not one single solution for all problems. There are patients in whom no sedation is required, and patients in whom only general endotracheal anesthesia will suffice. There are endoscopy centers in which anesthesiologist coverage will not be financially viable, and others in which it is indispensable. Anesthesiologists and endoscopists will continue to work together, but the division of labor will change. Emerging technology will shift the point at which we draw the line between acceptable and unacceptable practice. Although we do not expect that all the methods described in this issue will stand the test of time, we strongly suspect that many elements of the future practice of endoscopic sedation will be found in these pages. We hope you find this issue both useful and stimulating.New paradigms in sedation: pioneers get the arrows, settlers get the landJeff E. Mandel10.1016/j.tgie.2009.10.002Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7163163http://www.techgiendoscopy.com/article/PIIS1096288309000771/abstract?rss=yesThis chapter is concerned with “extended monitoring” and “advanced sedation” in gastroenterology. Topics discussed include capnography, monitoring depth of sedation, and computer-assisted propofol sedation. Although classical “hands-on” and “eyes-on” monitoring methods remain indispensable in monitoring patients undergoing gastrointestinal (GI) endoscopic procedures, some newer monitoring technologies are proving to be useful as well and are discussed. The chapter begins by examining the role that capnography plays in the respiratory monitoring of unintubated patients receiving sedation. Sample capnographic waveforms are provided and the results of recent GI capnographic studies are summarized. The discussion then switches to electronic processing of the electroencephalogram (EEG) as a means to estimate depth of sedation. Studies of processed EEG in the setting of GI endoscopy are also discussed. Finally, we discuss the use of computers to automate drug delivery for the purpose of providing sedation for GI endoscopic procedures.Extended monitoring in gastroenterology: capnography, monitoring depth of sedation, and computer-assisted propofol sedationD. John Doyle10.1016/j.tgie.2009.09.001Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7164170http://www.techgiendoscopy.com/article/PIIS1096288309000801/abstract?rss=yesMost endoscopic procedures in the USA are performed with some form of conscious sedation. The typical practice of midazolam and fentanyl is being supplanted by newer agents, including propofol, fospropofol, ketamine, and dexmedetomidine. These agents offer various advantages; propofol has significantly faster onset and offset, fospropofol avoids the problems associated with the lipid emulsion of propofol, and ketamine and dexmedetomidine avoid the respiratory depression associated with other sedatives. Understanding the properties of these agents may improve patient outcomes during endoscopy.New modalities and paradigms for sedation: “new sedation agents”Michael G. Rossi, Keith A. Candiotti10.1016/j.tgie.2009.09.004Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7171176http://www.techgiendoscopy.com/article/PIIS1096288309000795/abstract?rss=yesThis is a review of basic principles applicable to the use of propofol by trained endoscopists and nurses for endoscopy, without the involvement of an anesthesia specialist (an anesthesiologist or certified registered nurse anesthetist). The review also explicitly describes the nature of the current controversy surrounding the use of propofol by endoscopists, implies its origins in financial incentives, and outlines obstacles to the use of endoscopist-directed propofol.Endoscopist-directed propofolDouglas K. Rex10.1016/j.tgie.2009.09.003Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7177180http://www.techgiendoscopy.com/article/PIIS1096288309000837/abstract?rss=yesThe control of administration of drugs such as propofol is a task that is difficult to master. Two approaches to this task have emerged—target-controlled infusion, and patient-controlled sedation. In the first, a set point for drug in a hypothetical effect site is specified, and the controller delivers drug to hold the predicted concentration at that level. In the second, the patient administers small boluses of drug to maintain comfort. The theoretical basis of these approaches will be reviewed, available technology presented, and practical use of these devices discussed.Target-controlled infusions/patient-controlled sedationBasavana Gouda Goudra, Jeff E. Mandel10.1016/j.tgie.2009.10.001Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7181187http://www.techgiendoscopy.com/article/PIIS1096288309000783/abstract?rss=yesRespiratory obstruction is a frequent consequence of sedation due to the collapsibility of the velopharynx. Several approaches are available to eliminate this obstruction, including CPAP, mandibular advancement, nasal airways, and laryngeal mask airways. Practical approaches to the use of these measures are described.Airway appliances in endoscopyJeff E. Mandel10.1016/j.tgie.2009.09.002Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7188191http://www.techgiendoscopy.com/article/PIIS1096288309000813/abstract?rss=yesSpontaneous breathing is the default mode of ventilation for procedures in gastrointestinal (GI) endoscopy. Sedative–hypnotic medications profoundly impair respiratory control and airway patency. Fundamental physiology of hypoventilation is reviewed in the context of the patient presenting for interventional endoscopy. The endoscopy setting presents unique challenges for airway management and ventilation. These include a shared airway, patient-positioning, and out-of-Operating Room location. Strategies to support airway patency, oxygenation, and ventilation that are commonly employed in the controlled setting of the operating room can be effectively adapted to the GI endoscopy suite. Techniques discussed include nasal airway devices/CPAP, pressure-support ventilation, jet ventilation, and inhaled mask anesthesia.Endoscopic procedures are amenable to a variety of approaches for airway management, maintenance of oxygenation, and ventilation. Important considerations include (1) patient comorbidities, (2) nonstandard positioning, (3) the concept of a shared airway, (4) anesthetic-associated respiratory depression and upper airway collapse, and (5) type and duration of the procedure (lower endoscopy, upper endoscopy, or ERCP). This review provides practical strategies while addressing elements of basic physiology for the anesthesia provider in the GI endoscopy setting.Ventilation strategies in gastrointestinal endoscopyJoshua H. Atkins10.1016/j.tgie.2009.09.005Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7192196http://www.techgiendoscopy.com/article/PIIS1096288309000825/abstract?rss=yesAnesthesia providers increasingly find their services requested in endoscopy suites. There are numerous reasons, but the single most common factor is the increasing use of propofol. Despite clear trends indicating a greater demand for services, the safety record of out-of-operating room (OR) locations falls short of that in the OR. A variety of skills are required in the endoscopy suite, some of which are found in the core material of anesthesia training programs, and others that are not stressed in importance. The purpose of this article is to examine the methods of training that might be useful in producing anesthesia providers prepared for the challenges of the endoscopy suite and other out-of-OR locations, and speculate on how anesthesia training directors might address these needs.Training anesthesia providers for endoscopic sedationJeff E. Mandel, Richard R. Bartkowski10.1016/j.tgie.2009.09.006Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7197201http://www.techgiendoscopy.com/article/PIIS1096288309000850/abstract?rss=yesOffice-based anesthesiology (OBA) presents an opportunity for some anesthesiology practices to expand their scope and garner professional and financial growth opportunities. Practices that center their OBA feasibility analysis on their mission and objectives stand to be the most successful whether or not they decide to pursue an OBA venture. The steps in evaluating the risk/benefit of entry into OBA include a complete analysis of the anesthesiology practice's mission and resources, and an evaluation of the prospective office site to assure it offers a safe and financially viable practice venue. An effective OBA implementation plan deals with the attendant legal and regulatory requirements, a client satisfaction program, and development of an administrative infrastructure to support and monitor the success of the venture as defined by the practice's mission-based objectives.Practice management issues in office-based anesthesiologyMaria Galati10.1016/j.tgie.2009.10.003Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7202209http://www.techgiendoscopy.com/article/PIIS1096288309000862/abstract?rss=yesThe continued rapid expansion of office-based surgery and anesthesia (OBS/OBA) makes it a new frontier of healthcare. Though its early years were somewhat marred by some negative publicity and bad outcomes, oversight and regulation by professional societies, governments, and private industry has now begun to catch up with OBS/OBA practice. Clinicians and administrators must stay abreast of these ever-changing/evolving regulations and guidelines in order to remain in compliance with them as well as to provide safe and satisfying patient care. This article summarizes the current regulatory environment in which OBS/OBA practices and practitioners must operate.Regulatory issues in office-based surgery and anesthesiaDavid Wax10.1016/j.tgie.2009.10.004Techniques in Gastrointestinal Endoscopy 11, 4 (2009)2009-10-01Techniques in Gastrointestinal Endoscopy2009-10-01114S1096-2883(09)X0005-7210216